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Counselor Referral Form
Please complete the following information to refer a student for check in with school counselor.
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* Indicates required question
Student Name:
*
Your answer
Grade
*
Choose
K
1st
2nd
4th
School Format
*
Choose
Online Student
In the building student
Teacher
*
Your answer
Reason for referral (check all that apply/academic)
Attendence
Underachievement
skill deficiancy
study skills
organization
homework
other academic concern
Reason for referral (check all that apply/social/emotional)
Anger Management
Bullying
Social Skills/Friends
Withdrawn/Shy
Uncooperative/Defiant
Anxiety
Theft/Vandalism
Adjustment/Transition
Family Conflict
Health (Family or student)
Grief/Loss
Homelessness
Honesty
Self-Esteem
Other:
Comments:
Your answer
Level of Concern
*
High
Medium
Low
Referred by (please type name and relationship to student i.e. John Smith-parent, or Sally Jones-teacher)
*
Your answer
Submit
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