CAMS School Counseling Referral Form
Please use this form if you are a student at CAMS and would like to see a counselor OR if you are a teacher or parent who would like to refer a student.
Priority Level - When would you like to be seen by a counselor?
High (I would like to be seen today)
Medium (I would like to be seen by a counselor this week)
Low (I can wait until the counselor is available)
Which counselor would you like to see?
Mr. Firebaugh (6th Grade All; 7th grade A-L)
Ms. Moran (8th Grade All; 7th grade M-Z)
Whoever is available first
Last name of student referred:
First name of student referred:
Name of person referring:
Relationship to the student referred:
I wish to remain anonymous (Student will not know who filled this form out)
The student may know that I made this referral
Reason for Referral (Check all that apply)
Student demonstrates disruptive or inappropriate classroom behavior
Student talks about problems at home
Student is believed to be in an unhealthy relationship (romantic relationship, friendship, etc).
Student exhibits inability to cope with emotions appropriately (Anger Management)
Student shows signs of depression or possible suicide risk
Student recently experienced loss (death of a family member) or lives with someone chronically/terminally ill
Other students talk about the student's use/abuse of substances
Physical signs indicate possible substance use/abuse
He/she talks freely about substance use/abuse
Student or Student's girlfriend is pregnant.
(ADMIN USE ONLY DO NOT CHECK) Student stopped by counseling center
Please provide any additional information that would be helpful for the School Counselor to know
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This form was created inside of Botetourt County Public Schools.