LCS Referral For Counseling Services

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Student Name *

Grade Level *

Pre K

Referred By *

Referral Date *

YYYY

Concerns/Reason for Referral *

Please share any interventions to date and the result of those: *

Please share some of this students strengths and interests *

Other relevant information *

Who is preferred contact for this family and what is best method of communication? Has there been any home/school contact about this topic? *

Teachers: List two days/times that could be convenient for them to meet with us: *

Is parent/guardian aware of referral? (For school staff filling out)

Yes

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