E. O. Green School Counseling Services Referral Form for 6th Graders

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Thank you for taking the time to complete the referral form. The more information you can provide me regarding your concerns the better I can support you and the student.

Once I receive this form, I will contact parents regarding potential services, resources or referrals to community agencies.

Please keep in mind that:
School Counseling services will be provided through the current resources we have due to the need for distance learning.
Parent permission is required for all counseling services.
Not all students referred will receive school based services.

If you have any questions regarding this form or about services offered through the counseling program, please do not hesitate to ask me!

Today's Date *

Teacher *

Student Name *

Grade *

Parent Name *

Best way to contact the home *

Phone number

Both

Required

Parent Phone Number

Parent Email

Referred by:

Moods/Behaviors

Please check all that apply

Anxious/worried

Depressed/unhappy

Eating disorder/body image concerns

Hyperactive/inattentive

Shy/withdrawn

Low self-esteem

Self-harm

Aggressive behaviors

Stealing

Other:

Home Concerns

Please check all that apply

Illness/death in family

Family change

Suspected abuse

Suspected substance abuse

Conflict in the household

Other:

Reason for Referral (please be as specific as possible): *

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