Counseling Referral Form
Steps for making a referral:
1. Identify if a student needs to be referred. The referral form is used exclusively for a student who is dealing with social/emotional issues and it is affecting their academic performance and/or social well-being. ***If it is an emergency do not use the referral form. Please email and a counselor will come get the student or escort the student to the counseling office(room210). Do not leave the student alone.

2. Fill out the referral form.

3. A counselor will see that student as soon as possible. A determination will be made as to whether or not to extend counseling or if the issue has been resolved.

4. You will receive a confirmation that the student was attended to.

Email address *
Student First Name *
Your answer
Student Last Name *
Your answer
Student's Grade Level *
Teacher Name *
Your answer
Reason for Referral *
Additional Information *
Your answer
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