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Confidential Teacher Counseling Referral Form
Please fill out the following form for a student and the counselor will reach out to you to follow up.
School counselor:
Jennie Statczar, M.A., LPCC Email: Jennie@sopcc.org
Jennie@sopcc.org
or
jstatczar1@cdeducation.org
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* Indicates required question
Email
*
Your email
Student First Name
*
Your answer
Student Last Name
*
Your answer
Student Grade/Class
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Referred By (Teacher/Staff Name and contact information) :
*
Your answer
Reason for Referral: Emotional / Interpersonal Concerns
*
Behavioral / Emotional (self-discipline, self-control, anger management, coping skills)
Aggression / Anger Management
Dramatic Changes in Behavior
Bullying - Victim
Bullying - Bully
Self - Injurious (ex: cutting)
Peer Relationships (positive relationships, cooperative learning)
Social Skills (communicating, decision-making, empathy)
Self - Image / Self - Confidence
Grief and Loss
Study Skills
Homework Completion
Study Skills (organizational skills, time management, goal setting)
Other:
Required
Explanation:
*
Your answer
Are you aware of any significant changes in the child’s life?
Divorce
Death / Loss
Major Family Illness
Separation
Parent job change / loss
New Student
I am not aware of any changes
Other:
Explanation:
Your answer
How long has the problem been a concern?
*
Your answer
What changes would you like to see?
*
Your answer
Have you contacted the parent/guardian about your concern?
*
Yes
No
If you answered yes above, please list the Date of contact with parent:
Your answer
Best time to pull the student from the classroom:
*
Please list 1st choice and 2nd choice Day & Time
Your answer
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