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Parent Referral to School Counselor
Complete the following form for a counselor referral
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* Indicates required question
Parent(s) Name:
*
Your answer
Student's Name:
*
Your answer
Grade Level
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Concern/Reason for Referral (check as many as you need)
*
Academic
Behavior
Friendship / Peer Issue
Family
Other:
Required
How Urgent is this Referral?
*
Not Urgent
1
2
3
4
5
ASAP
I would like the counselor to... (check as many as you need)
*
to observe my child
to discuss concerns with me
to meet with my child
Required
How may the school counselor contact you?
*
Your answer
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