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Teacher Counselor Referral Form
Please share your concerns about your student by submitting this form. The appropriate school counselor will follow-up!
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* Indicates required question
Student's Name (First and Last)
*
Your answer
Student ID Number
*
Your answer
Academy
*
ACE
FBL
PSL
MED
STEAM
Don't Know
Referral Date
*
Your answer
Referring Staff Member
*
Your answer
Reason for Referral/Presenting Issues
*
Aggression/Anger/Fighting
Anxiety
Bullying
Conflict w/ peers
Defiance
Depression/Disinterested
Family Issues
Grief/Loss
Upset
Few Friends/Isolated
Crisis (Suicidal Ideation, Self-Injurious Behavior, etc.)
Other
Required
Is this student aware of the referral?
*
Yes
No
Please provide any additional information/details regarding your referral that would be helpful for the counselor to know. (Please be as specific as possible)
*
Your answer
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