Confidential Teacher/Staff Counseling Referral Form

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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.orgJennie@sopcc.org or jstatczar1@cdeducation.org

Email *

Student First Name *

Student Last Name *

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) : *

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: *

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:

How long has the problem been a concern? *

What changes would you like to see? *

Have you contacted the parent/guardian about your concern? *

Yes

If you answered yes above, please list the Date of contact with parent:

Best time to pull the student from the classroom: *

Please list 1st choice and 2nd choice Day & Time

Submit

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