Teacher/Staff Counseling Referral
Student First and Last Name
Your answer
Homeroom Teacher
Referring Teacher (If different from homeroom)
Your answer
Academic Reason for Referral (Check all that apply)
Social/Emotional Reason for Referral (Check all that apply)
He/She needs to see you
I would like you to see her
Comments: Anything that would be helpful for me to know before meeting with him/her.
Your answer
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