JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Counseling Referral Form
Please complete this form to request to speak with the school counselor. Your school counselor will see you once they are available. Note that this form is not monitored after school hours.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Is this an emergency?
*
No
Yes
Who is making this referral?
*
Choose
Student self referral
Teacher/Team Referral
Parent Referral
Administration Referral
Student Number
Your answer
Last Name
*
Your answer
First Name
*
Your answer
What grade are you?
*
6th Grade
7th Grade
8th Grade
How are you attending school?
*
Remote( At home)
In Person( Come to school)
Please provide your best contact information below. Example: telephone, or email.
Your answer
What is your concern/issue?
*
Grades
Problems with peers/other student
Schedule
Problems at home
Attendance
Resources
Required
Please list more information about your concerns.
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Henry County Schools.
Report Abuse
Forms
