School Counselor Referral Form for Parents & Teachers

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This form is for parents and teachers referring a student. PLEASE NOTE, IF YOU ARE A STUDENT AND NEED HELP, PLEASE EMAIL MRS. BOST DIRECTLY AT THIS EMAIL: carolmbost@gmail.com or fill out the student form located on the school website or in your Google Classroom.

Email *

Your Name (do not enter student name here) *

Best phone # for contacting you directly: *

Relation to Child: *

Parent

Teacher

Principal

Self

Other:

Student Name *

Name of Child's School

Parent/Guardian Name *

Grade *

Reason(s) for referral (check all that apply) *

Motivation

Parental separation/Divorce

Fears/Worries/Anxiety

Stressed

Friendship problems

Anger/Agitation

Grief and Loss

Depression

Withdrawn

Sadness

Suicide/Self-harm

Behavioral Concerns

Parental Concerns

Academic Concerns

Other:

Required

Other reasons for referral (please state below)

Are you aware of any relevant medical history, such as medication, diagnosis, family history of mental illness, etc?

To the best of your knowledge, are any other services/organizations involved with this child or family?

Please provide any further information regarding this referral

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