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Counselor Referral
Please submit this form if you would like Ms. Harrell to meet with your student. You may also call or email with any concerns.
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Classroom Teacher:
Your answer
Needs:
*
What would you like Ms. Harrell to address when meeting with this student? Please include as many details as you feel comfortable providing.
Your answer
How do you think this need can best be addressed?
Individual Session
Small Group Session
Class Lesson
Peer Mediation
Other:
Clear selection
Time Frame:
How urgent is the situation? How soon would you like Ms. Harrell to meet with your student?
Very Urgent: Today, if possible
Urgent: Tomorrow
Somewhat Urgent: Sometime this week
Less Urgent: Next week
Clear selection
Follow-up:
*
What type of follow-up would you like from Ms. Harrell after the situation has been addressed?
Email
Phone call
Note home
None
Other:
Required
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