Counseling Referral Form 2018-2019
To be completed by a parent/guardian.
Email address *
Counseling Information
Counseling MAY be beneficial for students who struggle with:
Behavior
Emotions
Peer Relationships
Family Changes
Academics
Motivation
Social Skills
...and a variety of other life situations....
Counseling Referral Procedure
1) Complete the online referral found on the St. Marcus website or contact Jackie K. via phone (414-333-6294) or email

2) Jackie K. will collaborate you about your concerns and discuss the options available for your student.

3) Jackie K. will complete a classroom observation and/or communication with Special Education/Deans/Directors about level of intervention needed and/or available for the student

3) Communication/Collaboration with teacher regarding intervention plan & data tracking
*If individual counseling or small group intervention is decided upon:
a) Teacher may complete a referral as well (if applicable)
b) Corresponding permission forms will be sent home & need to be returned before counseling can begin
c) Strengths and Difficulties Questionnaire completed by teacher/parent/student (if applicable)
d) Jackie K/counselor to set counseling schedule in collaboration with classroom/student schedule & communicated with teacher/adviser

4) Follow-up communication between all parties throughout the intervention will be expected.

*note: some steps may change depending upon severity and/or historical needs of an individual student

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