JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Refer a Student
Our school counselors are available to chat with students that request a time to check-in through this form. The days available are Tuesdays 8:30 am-3:30 pm. Check-ins are scheduled for 15-minute blocks and for non-emergencies. Please fill out the information below, and your school counselor will be in touch to confirm a day/time. .
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Teacher Name
*
Your answer
Student Name
*
Your answer
Student's Current Grade
*
Your answer
Student's Contact Information
*
Your answer
Reason for Referral
*
Your answer
Relationship to Student
*
Your answer
Is this a new concern or is this an ongoing concern/issue?
*
Your answer
What do you think your student needs help with?
*
Feelings
Friend Stuff
Other Kids
Family
Schoolwork
Responsible Decision Making
Other:
Required
Has this student experienced any traumas within this past year? (For example, divorce, loss of a loved one, medical emergency.)
*
No
Yes, please explain
Other:
Required
Does this student receive services outside of school
*
No
Grand Lake Mental Health
Osage Nation
Other:
Required
Does this student have an emotional disturbance (e.g., ADHD, depression)?
*
No
Yes
Required
Is the student developmentally immature?
*
No
Yes
Required
How is the best way to contact you, should I have any questions? Please include the time of day that is best for you. Thank you!
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Osage County Interlocal Cooperative.
Report Abuse
Forms
