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Nichols Elementary Parent Counseling Referral 2020-2021
Please complete the information below to refer your child for counseling.
*If you are experiencing an emergency please dial 911
Thank you!
Julia McDonnell
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* Indica que la pregunta es obligatoria
Student's Name
*
Tu respuesta
Grade
*
Elige
TK
K
1
2
3
4
5
Referred by:
*
Tu respuesta
What is your area of concern? Check all that apply.
Emotional regulation/coping skills
Self-esteem/growth mindset
Persistent low academic achievement
Withdrawn/isolation/loneliness
Personal health/hygiene
Family concerns
Friendship/social skills
Disruption/Attentiveness in class
Otro:
Please describe your concern or provide other important information:
*
Tu respuesta
Urgency (select one):
*
Low: This issue doesn't typically impact the student's learning. Please check-in with the student when you can.
Moderate: This issue somewhat affects the student's ability to be successful in school. Please see the student within the next 1-2 weeks.
High: This issue is greatly impacting the student's ability to be successful in school. Please see the student within this week.
Immediate!
Any other comments/concerns/questions ?
Tu respuesta
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