Counselor Referral Form - Badger Springs MS
To be used when needing assistance from a Counselor.
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.
I agree and understand.
Grade Level - Counselor
6th Grade - Timothy Gallegos
7th Grade - Gale Taylor
8th Grade - Anita Bazan-Barragan
Student Name (first and last)
Student ID Number
Relationship to Student
Self (select if the student is using the referral form)
Briefly describe the reason for the referral: (please keep this brief)
Attendance (first referral)
Attendance (second referral)
Please indicate any areas of concerns:
Inconsistent Participation in Virtual Learning
Behavior in Zoom Classroom
Please indicate any and all concerns:
Drastic change in mood
Self Isolates - Stays away from family or friends
Hostile and/or argumentative
Consistent Lack of Motivation or Participation in Zoom Class
Consistent inappropriate language (written and/or verbal) in Zoom classroom
Consistent Inappropriate Behavior in Zoom classroom
Page 1 of 2
Never submit passwords through Google Forms.
This form was created inside of Moreno Valley Unified School District.