Jay MS Student Request to see the Counselor

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If you are in physical danger or having thoughts of suicide or self-harm, call the Suicide Hotline: 988. PLEASE NOTE - THE COUNSELOR WILL NOT BE MONITORING THIS FORM BEFORE OR AFTER SCHOOL HOURS. IF THERE IS AN EMERGENCY, PLEASE CALL 988. Our counselor will respond and will visit with students during normal school hours.

Email *

First and Last name of the person making the referral: *

The person making the referral is a: *

Administrator

Family member

Friend

Parent/Guardian

Student (self referral)

Teacher

First and last name of the student being referred: *

What grade is the student in? *

7th

8th

Reason for a referral to see the counselor: (Please check all that apply.)

Academic - study skills, class/career guidance, trouble completing assignments, work habits, organization

Aggression/anger

Bullying and/or cyber bullying

Dramatic change in behavior

Family concerns - change in family, divorce, moving

Friendship/peer challenges/making friends

Grief - loss of a loved one

Inappropriate sexual behavior

Motivation

Nervousness/anxiety

Personal hygiene

Sadness/depression

Self-esteem/self-confidence

Self-harm

Social skills

Suicidal thoughts

Required

How long have these behaviors been going on?
*

Have there been any recent changes within the family?
*

Yes

Maybe

If yes, please explain:

Is there any other information I should be aware of?
*

Has the student received disciplinary measures for this behavior? If so, please explain. *

Is this visit considered a(n): *

Low priority - the student should be seen in 1-2 days

High priority - the student needs to be seen TODAY

Emergency - needs to be seen NOW

If the student is a virtual student, what is the best way to contact you?

Phone

Zoom

Clear selection

If the student is a virtual student and chose the phone as the best mode of communication, what is the student's phone number?

Submit

Clear form

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