K-5 Request for Counseling

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Thank you for making a student referral. All referrals will be addressed within 72 hours of receiving this form. If an emergency exists please contact me immediately through the front office.

Student Name (First Initial and Last Name) *

Grade *

Parent or Person Referring Student to Counselor *

Reason that student needs to meet with counselor. (Ex: anxiety, grief, divorce, health issues, previous bullying, homelessness etc.) *

What services are you hoping to receive from the counselor? *

Individual Counseling

Group Counseling

Phone Call from Counselor

Other:

Required

What is the best phone number to contact the legal guardian at? *

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