Laurel Springs Counseling Referral Form

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This form is used for a parent or teacher to recommend a child to receive counseling services. Counseling services are provided for children to address concerns that may be affecting them both academically or socially at school. They can also help your child build various skills they may be struggling with so they can have a successful school year. Counseling sessions are generally short term and may last between 6-8 weeks, however, can be extended based on your child's needs.

Please enter your child or student's name below.

Please enter you child's classroom teacher.

Please review the list below and check off any areas that apply to your child or student.

Social Skills- assistance with communicating appropriately to establish peer relationships.

Social Skills- assistance with using appropriate behaviors in group/classroom settings.

Self-Esteem- assistance with confidence building and assertiveness skills.

Organization skills- assistance with time management, focus, and attention.

Emotional Regulation- assistance with communicating feelings appropriately.

Other:

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Please provide a brief description explaining the concerns you have been seeing.

Please provide the best method of contacting you.

Phone

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Please provide your contact information below.

Submit

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