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Counselor Request Form
Teacher/Staff/Parents: Please fill out this form if you would like a student to be seen by the counselor.
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Email
*
Your email
Name of Person Completing this form:
*
Your answer
Student Name:
*
Your answer
Grade Level:
*
Your answer
What is the reason for referral today?
Please check all that apply.
Family Concerns
Family Illness/Tragedy
Peer Concerns
Anxiety
Conflict Resolution
Student has requested to visit counselor
Other: Specify in comments
Comments:
Anything that would be helpful for me to know ahead of time.
Your answer
A copy of your responses will be emailed to the address you provided.
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