Summit Drive Elementary School: Parent Referral for School Counseling Services
This referral form is for Parents and Guardians of Summit Drive Elementary School students. The school counselor, Jenni Dixon, will contact either you or your child within two school days of receiving this referral.  If this referral is urgent or you are concerned for the safety of your student, please contact the school counselor immediately at jkdixon@greenville.k12.sc.us. If the school counselor is unavailable, please contact the school office at 864-355-8800 or call 911.

Thank you,
Mrs. Dixon
2020-2021
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Date *
MM
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DD
/
YYYY
Time *
Time
:
What is your full name? *
What is the student's full name *
What is your relationship to the student? *
Grade Level
Clear selection
What is their teacher's name?
Academic Reason for Referral (Check all that apply) *
Required
Social Emotional Reasons for Referral (Check all that apply)
Explanation *
Rate the severity of this issue (impact on learning environment) *
Little Impact
Severe Impact
Concern Level:
Clear selection
Would you like for the school counselor to contact you before meeting with your student? *
Clear selection
Preferred method of contact: Please include either a phone number or email address *
Comments: Please include any additional information
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