School Counselor Referral Form for Parents
In support of students, parents, educators, and the community, school counselors provide a comprehensive services to promote optimal student achievement in academic, career, and social emotional development. Counselors are trained in child development, learning strategies, self management, and social skills. Adept at identifying individual student needs, school counselors provide education, intervention, and prevention support to help students reach their full potential. (American School Counselor Association)

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Email *
Student Name *
Student Grade Level *
Parent/Guardian First and Last Name *
Parent/Guardian Email *
Contact Number *
Preferred method of contact? *
Can I leave a message about your request on your voicemail if I am unable to reach you? *
Reason for referral? *
Any other information you wish to provide before the counselor meets with the student?
Confidentiality Clause:
School counselors are mandated reporters. All information will be kept CONFIDENTIAL unless a child reports 1) Someone is hurting him/her, 2) He/she is hurting him/herself, or 3) He/she plans to hurt another person.
A copy of your responses will be emailed to the address you provided.
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