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Counseling Referral Form
CONFIDENTIAL COUNSELING REFERRAL FORM
I
f you feel as though the referral is an emergency please contact:
Tia Follis
immediately
325-242-9255
* Indicates required question
Email
*
Record my email address with my response
Name of person making referral
*
Your answer
Please enter your phone number
*
Your answer
Type of referral
*
Group Therapy
Individual Counseling
Student name (first and last)
*
Your answer
Gender
*
Male
Female
Other
Student's grade
*
Your answer
Has the student experienced any of the following (check all that apply):
*
Academic Issues/Truancy
Anger/Violence
Anxiety/Excessive worry
Appetite/Eating changes
Attention problems
Bereavement
Bullying
Depression
Disruptive behaviors
Hallucinitions
Low Self-Esteem
Self-Harm
Sleep Issues
Substance Abuse
Suicidal Thoughts
Trauma
None of the above
Required
Priority Level
*
Low (schedule when available)
High (schedule as soon as possible)
Emergency (see now- please call or text Tia Follis 325-242-9255)
Clarify the reason for the referral:
*
Your answer
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