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Elementary School Counselor Referral Form
Parents: Please use this form if you feel your child would benefit from meeting with the School Counselor and would like Mrs. Pottorff to meet with your child.
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* Indicates required question
Student
*
Your answer
Classroom Teacher
*
Your answer
Grade
Choose
Kindergarten
First
2nd
3rd
4th
5th
6th
Name of person making this referral
*
Your answer
Reasons for referral (Check all that apply):
*
Aggression
Dramatic change in behavior
Bullying-target
Bullying-perpetrator
Self-Injury (cutting, biting, head-banging, etc.)
Anger Management
Physical Fighting
Stealing
Lying
Difficulty in peer relationships
Social skills
Family concerns
Change in family dynamics
Cries easily/often for age
Self-image/Self-esteem
Grief and loss
Always tired
Sadness
Worried/scared
Defiant
Impulsive/Hyperactive
Inattentive/Distracted
Disruptive
Withdrawn
Anxious/Nervous
Lacks motivation
Work completion
Organizational skills
Personal hygiene
Suicidal ideation
Other:
Required
Explanation of reasons:
*
Your answer
Mrs. Pottorff will be contacting you to follow-up with your concern, which is the best way to do so:
Email
Phone
Clear selection
Please add your phone number or email you would like Mrs. Pottorff to use to contact you.
Your answer
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