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Parent Referral to School Counselor
Please complete this form if you would like for Mrs. Fetters, our School Counselor, to speak with your child.
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* Indicates required question
Referring Parent/Guardian
*
Your answer
What is your child's name?
*
Your answer
What grade is your child in?
*
4th grade
5th grade
Who is your child's HOMEROOM teacher?
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Your answer
Which would you like to refer your child for?
*
A check-in on something specific
Short-term counseling (typically meet weekly for 4-6 weeks)
Small group counseling
What area of concern do you have for your child?
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Anxiety
Behavior
Bullying
Emotional Concerns (i.e. cries often, low self-esteem, angers easily, etc.)
Friendships
Grief/death of a loved one
Social Skills
Other:
Required
Please give me more information on why you are referring your child to speak to our School Counselor.
*
Your answer
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