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School Counseling Referral Form - Teacher
Please answer the following questions to refer a student for counseling services.
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
Teacher Name
*
Your answer
Student Name
*
Your answer
I am recommending this student for counseling services for support with:
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Friendships/Conflict Resolution
Mean Behavior Towards Others
Self-Esteem
Self-Control/Self-Regulation
Anger Management
Stress
Family Issues
Behavior
Study Skills
Social Skills
Grief
Other students are being unkind to student
Home Safety Concern
Other:
Required
What are some of the student's strengths?
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Your answer
Please list 1-2 time slots that I could meet with this student regularly if needed.
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Your answer
How severe is the issue?
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Not severe at all (can wait to be seen)
1
2
3
4
5
Extremely severe (needs to be seen ASAP)
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