School Counselor Referral Form 2022-2023

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Please complete the form below if you would like to refer a student or yourself to the school counselor. Counselors are available to meet with students M-F from 8:00am - 3:00pm.
IF THIS IS A MENTAL HEALTH EMERGENCY AND IT IS OUTSIDE OF THE COUNSELOR HOURS, PLEASE CALL 911

Email *

Date *

YYYY

What is your name? (First and Last Name)

I am the *

teacher

parent/guardian

student (self-referral)

Other:

The best phone number to reach me is: *

What is the name of the student you would like to refer? (First and Last Name) *

What grade is the student in? *

Who is the homeroom teacher? *

Please describe the reason for referral. *

This... *

is very important (will be seen within 1-2 school days)

can wait (will be seen within 2-3 school days)

A copy of your responses will be emailed to the address you provided.

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