LES School Counseling Referral Form

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This form is for school staff members to request school counseling services for students. Any information shared in this form is for the use of the school counselor and will NOT be kept in the student's cumulative files.

This form is NOT for reporting emergencies. Please contact your school's administration, counselor, or SRO in the event a student is at risk to self or others. *Note that bullying concerns should also be reported to the administration. *Concerns of child abuse should immediately be reported to Monica Hardin, LES Child Abuse Coordinator & School Counselor.

Thank you for helping us better serve our students.

Email *

Record my email address with my response

Date *

YYYY

Referring Staff's Name *

Student's Name *

Student Grade *

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