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STUDENT School Counseling Referral Form
Please complete this referral and submit. Mrs. Pike will call for you when she is available. If you have an emergency, please let your teacher know so Mrs. Pike can be notified immediately.
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* Indicates required question
Student Name (first and last)
*
Your answer
Grade
*
K
1
2
3
4
5
6
Teacher
*
Your answer
REFER TO:
*
aimee.pike@meade.kyschools.us
What would you like to see the school counselor about?
*
Friendships
Family
School Work
Myself
Other
What are some things you have already tried to help you with this problem?
*
Your answer
When do you need to see the counselor? Emergencies should be reported to your teacher.
*
Sometime soon (within 2 or 3 days)
As soon as possible. This is a big problem I can't solve. (by the end of the day)
Submit
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