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School Counselor Referral Form
Please share your concerns about your student by submitting this form. The appropriate school counselor will follow-up!
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* Indicates required question
Email
*
Your email
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Grade
*
Your answer
Referring teacher/staff member
*
Your answer
Barrier/Concern
*
Bullying
Death in Family
Divorcing/Separating parents or caregivers
Home Life (unsafe housing, parental concerns, hygiene, etc.)
Mental Health (signs of anxiety, depression, low self-esteem, etc.)
Peer Conflict
Social Skills
Student requested to see counselor for known or unknown reason
Other:
Please provide any additional information/details regarding your referral that would be helpful for the counselor to know.
*
Your answer
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