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Middle School Counselor Referral
Please fill out the form to your best ability and the Middle School Counselor will be in contact with you soon.
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* Indicates required question
Your Name
*
Your answer
What is your relationship with the child? (Parent, Student's Teacher, Learning Coach, Community Family Advisor, etc.)
*
Your answer
Student last name, first initial (ex. Smith, J.)
*
Your answer
Student ID
Your answer
Student Grade
*
6
7
8
Required
Brief Description of issue
*
Your answer
What next steps would you like to see for this situation? (Check all that apply)
*
Phone Call Home
Small Group Meeting
SFRC (Student Family Resource Coordinator) Referral
Team Collaboration Meeting
Class Discussion
A counselor one-on-one with student
Other:
Required
If you answered "other" above, what next step would you like to see?
Your answer
Would you refer this student for Group SEL Sessions? (Check all that apply)
*
No
Depression
Grief/Loss
Anxiety
Social Relationships
Bullying
Divorce/Separation
Other:
Required
Would you like a follow up from the Elementary School Counselor in this matter?
*
Yes
No
Other:
Required
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