Counseling Referral Form

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Referral form for students who need to see the counselor. Please select the category they need assistance with. If you need to provide more detailed information please contact Ms. Ealy at ext. 7732.
*If the student is in crisis, please call ext. 7732 and I will meet with the student as quickly as possible.

Email *

Student Name *

Reason for counseling appointment *

Academic

College/Career

Personal/Social

Required

Brief explanation of concern or issue *

Who is requesting the appointment? *

Student

Teacher

Parent

Other:

Required

Priority *

LOW (Schedule when Available)

HIGH (Schedule as soon as possible)

EMERGENCY (See Now)

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