School Counseling Referral

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Referral for school counseling.

Email *

Person Completing the Referral *

Student: First and Last Name *

Student Grade Level *

Reason for Referral

*** If this is an instance of self-harm, threats or harm to others, or suicidal ideation, please text the counselor immediately or call the school and speak to the principal ***

If other on previous question, please explain

History of referral problem

Any actions taken- parent contacts, conversations with the student, remedies, etc.

Anything else you need the counselor to know

Send me a copy of my responses.

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