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Small Group Referral
Please complete this form to refer a student for a small group.
*Small groups aren't for every student, and participation must be approved by parents.
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* Indicates required question
Your Name:
*
Your answer
Student's First Name:
*
Your answer
Student's Last Name:
*
Your answer
Grade:
*
Your answer
What's a strength that this student possesses?
*
Your answer
Your concern for this student:
*
academic concerns (organization, study skills, motivation, etc.)
emotional issues (anxious, grief, angry, sad, aloof, etc.)
social issues (friends, disconnected, isolated, conflict resolution, etc.)
behavior (self-control, courage to make good choices, etc.)
family issues (divorce, loss of employment, birth of new sibling, remarriage, etc.)
Other:
Required
Primary goal of counseling for this student:
*
Your answer
Interventions you've tried:
*
Individual instruction
Tutorials
Peer tutor/PAL
Contacted parent
Conferenced with student
Hands on/Tactile activities
Pre-Taught vocabulary
Preferential seating
Stress ball/stress relieving activity
Brain break/relaxation technique
Counselor referral
Office referral
Other:
Required
Comments and/or questions:
Your answer
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