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Student School Counseling Referral Form 2023-2024
I will respond to your request as soon as possible (1-3 days). If you need help with something sooner than that, please talk to your teacher or another staff member at our school.
If you are in a crisis (there is a serious threat to yourself or others) and you are not at school, call 911 or call/text the Suicide Prevention Lifeline at 988.
* Indicates required question
Email
*
Record my email address with my response
Date
*
MM
/
DD
/
YYYY
Student's Name (first and last)
*
Your answer
Grade
*
K
1
2
3
4
5
Who is your teacher?
*
Your answer
Size of the problem (How can I help you)
*
Rain (not urgent): Some examples include things like stress, family concerns and friendship problems.
Thunder (important): Some examples include things like feeling anxious, depressed or a family illness.
Storm (a big deal): I am at risk of danger, someone else is at risk, someone is hurting me or making a threat.
Good News: I want to share something positive with you!
Reason for request
*
Family/ Home
Friends/Other Student(s)
My Feelings
School
Something Personal
Required
Tell me a little more about your problem:
*
Your answer
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