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Prairie Elem PreK-2nd Counseling Referral Form
Please fill out this form if you are referring a student for PreK-2nd. These responses will be sent to Layla Touchet, the school counselor for these grades.
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* Indicates required question
Email
*
Your email
Student Name
*
Your answer
Teacher Name
*
Your answer
Grade
*
PreK
Kindergarten
1st
2nd
Referred by:
*
Your answer
Parent's Name
*
Your answer
Student lives with:
*
Your answer
Best Contact Number for Parent
*
Your answer
I am referring the above named student for the following reason(s):
*
Absences
Academic skills
Always tired
Bullying
Sudden Changes
Death
Divorce
Family Concerns
Fighting
Friends
Homework
Hyperactivity
Inattentiveness/Focus Concerns
New Student
Suspected Abuse
Self-Concept
Social Skills
Socially Withdrawn
Other:
Required
Any additional comments
Your answer
Best Time to See This Child:
*
Your answer
Has the parent been contacted before?
*
Yes
No
If yes, what number was used to contact the parent?
Your answer
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