HVES Parent/Caregiver Referral Form
Thank you for reaching out to your school counselor. Be aware that we do not check email except during school hours. If this is a crisis or emergency call 911 or go to your local emergency room.

School Counselors differ from mental health counselors in that we provide systemic support through a multidimensional intervention, not 1:1. School counselors provide individual, group, and classroom counseling sessions as short term and solution-focused. Mental Health Counselors provide individual counseling sessions and function as long term therapy.

Confidentiality- Information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about your child (how are they coping in class, strategies to help, etc.) All communication will take place only on a need-to-know basis.

E-mail transmissions may contain confidential health information that is privileged and legally protected from disclosure by the Health Insurance Portability and Accountability Act (HIPAA).  This information is intended only for the use of the individual or entity named in the email.  If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this e-mail is strictly prohibited.


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Grade level of child/children: *
Required
Teacher Name *
Student Name *
Parent/Caregiver Name *
Names of siblings?
Best Phone Number (please enter (xxx) xxx-xxxx)
What are your concerns? *
Please briefly describe your areas of concern below:
I need help:
Could you please...
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