Parent Referral Form

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You can use this form to contact Mrs. Frayer, the School Counselor if you believe your child needs to talk about a problem they are having at school or home.

School-based support is brief, solution-focused counseling, so if you believe your child needs more long-term support, please ask for assistance with a referal to a mental health provider.

Your student's first and last name: *

Your student's teacher and/or grade: *

Parent/Guardian Name *

Parent/Guardian Phone Number *

What kind of problem is your student having? Check as many boxes as you need. *

Difficulties with peers (frequent arguing, "drama")

Bullying

Bus concerns

Feeling nervous or worried about something.

Not wanting to come to school

Feeling lonely or left out.

Having trouble making friends.

Feeling sad a lot of the time.

Someone special to my child is sick or has passed away.

Difficulty with academics.

Difficutly transitioning (new to this school and missing old school and friends).

The adults in my child's life are not getting along.

Parents are separating or getting a divorce.

Other:

Required

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