Cottage Hill Counseling Referral Form

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Please fill this form to make a referral to school based counseling. The Counselor will contact you regarding the referral. Parent permission is required to participate is school counseling.

Contact Michele Neeb, mneeb@prsd.us or 530-205-5376 with questions.

Name of person referring/relationship *

Last name of Teacher *

First 3 letters of first and last name of student

e.g. MicNee

Grade Level

1st

2nd

3rd

4th

5th

Clear selection

For staff only cumulative record review completed

Yes

Clear selection

For staff only academics/grades

Mastery of Standards

Meets Standards

Average to below grade level in one or two subjects

Below grade level standards in three or more subjects

Unknown

Clear selection

Primary Concerns *

Social e.g. problem with peers

Emotional e.g. responses outweigh situation

Argues frequently with peers/staff and/or others

Stress Management

Anxious behaviors

Sad affect 6+ months

Failing grades

Absences over 10%

Failure to return homework

Repeated physical contact with peers

Repeated physical contact with staff

Repeated defiance of staff

Requesting information about homelessness resources

Other:

For staff only family contact with dates

Does the student have a 504 plan?
*

Yes

List 504 accommodations if applicable:

Does the student have an IEP?
*

Yes

Has the Case Manager been contacted?
*

Yes

N/A

Is the student aware of the referral?
*

Yes

Do the Guardians give consent to school counseling?

Parent consent is required.

Yes

Write guidance group requested and/or other information: (e.g. Stress Busters, Ready to Regulate)

*all groups meet for six sessions during school hours, generally one time weekly, parent permission is required

I understand all School Staff are mandated reporters.

Yes

Maybe

Clear selection

Submit

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