School Counseling Referral
Individuals should complete the form below when referring a student to their School Counselor.

Thank you for reaching out to your school counselor. Be aware that we do not check email except during school hours. If this is a crisis or emergency call 911 or go to your local emergency room.

Confidentiality- Information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about your child (how are they coping in class, strategies to help, etc.) All communication will take place only on a need-to-know basis.
Email address *
Grade *
Student's Full Name *
Does the student have an IEP? *
Reason for Referral (mark all that apply) *
Concerns: *
Contributing Factors or other known information:
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