Counselor Referral Form - Badger Springs MS
To be used when needing assistance from a Counselor.
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Email *
I understand that the school counselor may not receive this request immediately.  If this is a physical or mental health related crisis please contact emergency services at 911.  I also understand that anything discussed with the school counselor or anything my student discusses with the school counselor is confidential (12 yrs and older) unless the parent or student discloses that they want to hurt themselves or they want to hurt someone else (must be an identifiable victim), or someone is hurting them. Please allow 24-48 hours for a counselor to contact you regarding your concerns. *
Grade Level - Counselor *
Student ID Number *
Student Name (first and last) *
Referred By: *
Relationship to Student *
Briefly describe the reason for the referral: (please keep this brief)
Attendance Concerns:
Please indicate any areas of concerns:
Please indicate any and all concerns:
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