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Parent Referral to School Counselor
Complete the following form for a counselor referral. This is for non-emergent situations. Contact your school counselor for emergent situations ASAP.
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* Indicates required question
Parent(s) Name:
Your answer
Student's Name:
*
Your answer
Grade Level:
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
Concern/Reason for Referral
Academic
Behavior
Friends
Family
Peer Mediation
Other:
How urgent is this referral?
Not Urgent
1
2
3
4
5
ASAP
Clear selection
I would like the counselor to...
observe my child
discuss the concerns with me
meet with my child
Would you like the school counselor to contact you? If so, how may the school counselor contact you? (ex: email, phone, via student)
Your answer
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