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Parent/Guardian School Counseling Referral Form
Thank you for taking the time to fill out this form!
Please feel free to call/email any of the School Counselors if you have any questions.
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* Indicates required question
Email
*
Your email
Referring Parent/Guardian's Name
*
Your answer
Contact Phone Number
*
Your answer
Email address
*
Your answer
Preferred Method of Contact
*
Phone
Email
Child's Name
*
Your answer
Teacher's Name
*
Your answer
Grade
*
Choose
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Primary Area of Concern
*
Friendship/Social Skills
Emotion Regulation/Coping Skills
Self-Esteem
Other:
Description of Concern
*
Your answer
Have you discussed this concern with your child's teacher?
*
Yes
No
Other:
Is your child aware of this referral?
*
Yes, my child is aware of this referral
No, this has not been discussed with my child
Any notes or additional information that would be helpful for the School Counselor to know prior to talking with your child.
*
Your answer
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