7th Grade Student Referral Form 2020-2021
This form is for students to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If you report any abuse, neglect, or intent to harm, then the Department of Children's Services at 877-237-0004 will be contacted; as appropriate.
* Required
Email address
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Your email
Your Last Name, First Name
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Your answer
Your Grade
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6th
7th
8th
Required
Level of Urgency (Need)
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Priority 1- Someone is in serious (physical) danger and I need adult help (Concerned for myself or someone else)
Priority 2- I need to talk to someone really bad! (Today or tomorrow)
Priority 3- I need to see you but it's not an emergency.
Priority 4- FYI- For Your Information (I don't need to see you but I want you to know)
Which category best describes why you need to speak with me? (This helps me, help you...See examples below)
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Personal/Social Matters - (Conflict/Drama)
Academic Support - (Grades)
Stress/Anxiety (Due to school or any other reason)
Anger Management
Home (Move, divorce, siblling, parents....)
Other (Anything not listed above)
Tell me why you need to see me in detail based on what you choose above.
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Your answer
Have you talked to your parent/guardian about this situation?
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Yes
No
HOW have you attempted to make the situation better?
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Your answer
Submit
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