Counselor Referral for St. Pius X Catholic School

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Complete this form if you believe your child needs to be seen by the school counselor. Please note, Ms. Hughes is only on campus Mondays and Thursdays. If this is an urgent matter, please call the SPX main office @ 210-824-6431. If this is a crisis/emergency, please call 911.

Student Name *

Student Date of Birth *

YYYY

Homeroom/Grade Level Teacher *

Reason for Referral *

Academic Achievement

Behavioral

Emotional

Social

Mistreatment

Other:

If this is an urgent matter, please call the SPX main office 210-824-6431. If this is a crisis/emergency, please call 911.

Required

Person Completing Referral/Please write in your name *

Service Requested *

Classroom Observation

Consultation

Counseling

Other:

Required

Explanation of Request for Services *

Submit

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