BPA 22-23 School Counseling Referral Form 
Please fill out the below form if you would like to request for the School Counselor, Ms. Mellick, to meet with your student.

For EMERGENCY situations, do not complete this form. Contact Ms. Mellick or an Administrator directly.

You will receive contact within 48 hours of completing this form.

*NOTE: Ms. Mellick is available to meet with students regarding areas of their academic, behavioral, social, and emotional needs. Services include short-term individual counseling, group counseling, and classroom instruction. School counseling services are aimed at removing barriers to a student's academic progress and socialization of the student within the school community. Services are not intended as a substitute for psychological counseling, therapy, or diagnosis. It is the responsibility of the parent/guardian to determine whether additional services are necessary. If needed, our social worker can help families with community based referrals to a mental health provider.
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Email *
Date *
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Name of Referring Person *
Your Email Address *
Best Contact Number
Relationship to Student *
If you are a teacher, have you contacted the parent? **Parents must be contacted by the teacher before a referral to the counselor is submitted.**
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If you are a teacher, what are the best days and times for the individual session?
Student's Last Name *
Student's First Name *
Homeroom Teacher *
Grade Level *
Required
Academic Concerns (Check all that apply--if n/a leave blank)
Personal/Social Concerns (Check all that apply--if n/a leave blank)
(Optional) Please list any goals you think your child/student should work on during time with Ms. Mellick.
(Optional)  Please include anything that may be helpful for Ms. Mellick to know ahead of time to better assist your child/student.
A copy of your responses will be emailed to the address you provided.
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