McDonald's Counseling Referral Form
Once you complete and submit the form an email will be sent directly to the counseling center. The student will be added to their list of students to see.

**If the presenting problem is dealing with some type of harm that qualifies as an emergency (the student is being harmed by someone, the student is planning to harm someone else, or the student is self harming) secure the student then please contact a counselor/administrator via phone AND this form.
 
If the student is being abused in any way please contact CPS immediately, remember you have 48 hours to report suspected or possible abuse.** 1(800) 252-5400
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Email *
Student First Name *
Only one student name at a time!
Student Last Name *
Only one student name at a time!
Teacher Name
Type name only if teacher is referring.
Student's Grade Level *
Reasons for Referral *
Required
On a scale from 1 to 10 rate the urgency of your safety need. *
Captionless Image
Need to talk but safety not an issue
Extreme fear for safety
Please include a summary of the presenting problem. *
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