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2023-2024 Counseling Referral Form
School Year 2023-2024
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* Indicates required question
Email
*
Your email
Name (Person making the referral request)
Your answer
Referred By:
Choose
Director
Behavior Specialist
Teacher
Staff
Parent
Student
District Social Worker
Campus Counselor
Campus
Choose
Southwest Campus/ECC
Northeast Campus
East Campus
Today's Date
MM
/
DD
/
YYYY
What time of day did the concern arise?
Choose
Morning 7am-11am
Midday 11am-1pm
Afternoon 1pm-3pm
After-school
Student Name
Your answer
Grade Level
Choose
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Are parents/guardians aware of your concerns?
Choose
Yes
No
Services Received
Choose
Special Education Services
Section 504
MTSS (Academic)/RTI
ESL Services
Dyslexia Services
Other
Level of Referral
Choose
Tier 3 (Suicide Risk/harmful to self and others/Physical,Sexual Abuse or Neglect)
Tier 2 ( Excessive attendance concerns/Trauma/Grief and Loss)
Tier 1 ( Whole Group Support Only-Character Education Development/College Career Readiness)
What interventions have been provided?
*
Re-taught/practiced behavior expectations/skills
Modified environment based on known predictors
Identified environmental factors
Provided a structured choice
Review discipline data for patterns and trends
Met with team/student to identify more support
Collaborated with ____team _____admin
Contacted parents
Other:
Required
Counseling Type
*
Choose
Individual
Small Group
Whole group (classroom setting)
Explanation- Please be specific and share detailed information. (Include dates/times/settings)
Your answer
Administration Use Only (Counselor or Social Worker Only)
Choose
Further observations needed to determine if counseling services are needed
On-going counseling services needed
Outsourced to University of Texas (TCHATT-Services)
Outsourced to DSW (District Social Worker)
A copy of your responses will be emailed to the address you provided.
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