Parent Referral Form for Counseling
This form is for parents that would like for their child to see the school counselor. Once the parent fills out this form please email stephanie.donnnell@bushlandisd.net to let her know you submitted the form.
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What is your child's name? *
What grade is your child in this year? *
Who is your child's teacher? *
What is today's date? *
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What is your primary concern/reason for the referral? *
Do you feel that your child is on grade level in reading? *
Do you feel your child is on grade level in math? *
Has your child been retained? *
In your opinion, how is your child's school performance? *
Does your child have any behavior concerns at school/home? Please describe. *
Has your child experienced any adverse childhood experiences listed below. Adverse Childhood Experiences (ACES) can be highly stressful experiences that can happen to any of us before we turn 18. ACEs are not our fault, and we didn't have control over when or why they happened. Or they can be an ongoing struggle where our safety, security, trust, or even our very sense of self is threatened or violated. When the stress of a particular adversity doesn't go away, that stress can literally get under our skin and become toxic if we don't have adequate support from our parents or caregivers. After submitting this form if you would like to learn more about ACEs then go to www.numberstory.org where you can learn more about positive, tolerable and toxic stress. *
How do you feel your student is socially with peers? *
How do you feel your child is emotionally? *
Who is making this referral? *
What personal/social areas are you most concerned about? *
Required
Check the academic skills you are concerned about that apply to your child. *
Required
Check which academic areas are you most concerned about at this time. *
Required
Check all personal and social development skills that your child does at this time. *
Required
Check the following career skills that your child demonstrates. *
Required
What medications is your child on currently? *
What have you tried to help your child with their current issues that you are concerned about? *
If your child's issues that you are concerned about were fixed/solved, what would you see your child do differently/correctly? *
What are some of your child's strengths, interests and abilities? *
Check any of the following that apply to your child at this time. *
Required
Have you met with your child's teacher about your concerns? *
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