Parent Referral Form 2020-2021
Parents will use this form to request School Counseling support for their child. Please provide some information to help Mrs. McKiddy best support your child. This will be a brief check-in to provide support with social-emotional needs to best prepare them for success in the classroom. Following the student check in, it may be decided upon that your child may benefit from individual or small group counseling. Collaboration will then take place between yourself, the school counselor, and classroom teacher to ensure these services best meet the needs of your student.
* Required
Email address
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Your email
Student Name
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Your answer
Building
Spencer
Hornung
Clear selection
Grade
JK
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
Clear selection
Teacher
*
Your answer
Area of Concern
Behavior
Anxiety
Emotional Support
Coping Skills
Peer Relationships
Problem Solving
Work Completion
Motivation
Other:
Describe the concern, with details of how it is impacting their behavior and success in the classroom.
Your answer
Please Check all the following that you understand and agree to:
*
I understand that my school counselor provides school counseling services but does not provide therapy.
I acknowledge and allow for my student to receive school counselor support both in person or virtually.
I understand that my school counselor will break confidentiality if your student has thoughts of hurting themselves, thoughts of hurting others, or if someone is hurting them.
I understand that there may be additional limitations to confidentiality if meeting with their school counselor virtually, which may include unintended viewers or recipients.
Your student promises to adhere to appropriate student conduct while working with their school counselor, both in person or virtually.
If connecting virtually, I promise to provide my child with an opportunity to talk with the school counselor in a space that is free from family members, interruptions, and distractions.
I allow my student to participate in small group or individual based counseling as determined between the school counselor and student parent(s).
Required
Parent: Please type your name below stating that you have read the above disclosure statements with your child.
*
Your answer
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