Grenada Middle School's Parent/Community Online School Counseling Referral Form 23-24
Thank you for making a school counseling referral on behalf of a student. If an emergency exists please contact call 911, SUICIDE Hotline (Call or text 988) or the middle school at 662-226-5135 to speak to an administrator or a counselor during school hours.

The term “counseling” may seem scary, but it should be a positive process that guides a person to become more self-aware, gain positive coping skills to deal with life’s challenges, and achieve healthy emotional management.

-GMS Counseling Department
Kiara Johnson, Counselor
Ashley Harrell, Counselor
Tiffany McCuiston, Counseling Secretary
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Date: *
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Student Name: Full First Name and Last Name  *
Please select the level of urgency below. *
Grade of student being referred *
Name of person making this referral (Please type your full name) *
Please provide an email address and/or a valid contact number to be reached at.
 *
Who are you to the student being referred? *
Have you made a parent/guardian contact regarding this concern? *
Description of the concern (Check all that apply) *
Concerns observed at school
Required
Other information
Home Situation (Check all that apply) *
Do you have personal information about any of the following?
Required
What actions were taken on the student's behalf prior to referring this student to the school counselor? *
Parent/Peers/Other relatives: Please ensure that all phone numbers and/or email addresses are updated in case the school counselor may need to contact you on behalf of the individual being referred. *
Required
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