HFB School Counseling Referral

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Please complete this form if you would like to refer a student for School Counseling services. I will follow-up with you if I have additional questions and to work on scheduling.

Thanks so much!
Steven Rockey
Counselor
Hoffman-Boston Elementary

Email *

Student's Name: *

Student's Grade: *

Student's Teacher: *

Your Name: *

Relationship to the student: *

Parent/Guardian

Regular Education Teacher

Special Education Teacher

Student (self-referral)

Other:

What is the best way to contact you with additional questions? *

Please enter a phone number or e-mail address

Areas of Concern: *

Physical Aggression

Verbal Aggression/Arguing

Bullying

Inattention/Hyperactivity

Anxious Symptoms

Depressive Symptoms

Self-Harm

Trauma

Abuse/Neglect

Attendance/Truancy

Homelessness

Grief

Divorce

LGBTQ+ Issues

Grades/School Goals

Social Skills/Friendship Making

Health Concern

Other:

Required

Describe your concerns: *

Please include as much data (for example, discipline referrals or attendance information) as possible!

What times of day is the student available to receive services?

8:00 AM

8:30 AM

9:00 AM

9:30 AM

10:00 AM

10:30 AM

11:00 AM

11:30 AM

12:00 PM

12:30 PM

1:00 PM

1:30 PM

2:00 PM

2:30 PM

3:00 PM

3:30 PM

Monday

Tuesday

Wednesday

Thursday

Friday

Have you contacted the student's family about your concerns and to let them know you will be making the referral? *

Yes

N/A

Other:

Do you have any other information to share?

Submit

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