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2019 Counselor Referral Form
****** If a student is having a SUICIDAL IDEATION please immediately call the office, and ask for assistance. Please do not leave student alone. ************
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Student Name
Your answer
Teacher Referring
Your answer
Check which concerns you may have?
Excessive absence/tardiness
Friend Problems
Home Issues (Family Issues)
Low- Self Confidence
Outburst
Academics
Depressed/Withdrawn
Grief
Other:
Briefly explain your concern(s)
Your answer
What have you tried to help the student?
Your answer
Other Information?
Your answer
Convenient time for me to visit with student(s)
Your answer
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