LES School Counseling Referral Form

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This form is for school staff members to request counseling services for students. Any information shared in this form is for the use of the school counselor and will NOT be kept in the student's cumulative files. Any information submitted through this form may be shared with the School Mental Health Team if the situation merits an external referral. Thank you for helping us better serve our students.

This form is NOT for reporting emergencies. Please contact your school's administration, counselor, or SRO in the event a student is at risk to self or others.

Date *

YYYY

Referring Staff's Name *

Student's Name *

Student Grade *

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