Counseling Referral Form(Faculty/Staff)
Please fill out the following referral form for the identified student. Thank you for taking your time to support our students and get them the help that they need! 
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Your Name *
Student's name *
Student Grade Level *
Level of concern *
Area of Concern *
Please describe the mental health concerns that you have regarding this student and when they began. *
What changes would you like to see in the student?
What have you and/or the student done in the past to address the presenting problem(if applicable)?
Has the student disclosed abuse, neglect, self-harming thoughts/actions, or anything that may merit a police report? If yes, please explain. *
Is the student aware that you are making this referral?
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Please include any other relevant information you feel will be helpful for the counselor.
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