Counseling Referral Form (Staff Referring Students)

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Once you complete and submit the form an email will be sent directly to the counseling center. The student will be added to their list of students to see.

**If the presenting problem is dealing with some type of harm that qualifies as an emergency (the student is being harmed by someone, the student is planning to harm someone else, or the student is self harming) secure the student then please contact a counselor/administrator via phone AND this form.

If the student is being abused in any way please contact CPS immediately. Remember that you have 48 hours to report suspected or possible abuse.** 1(800) 252-5400

National Suicide Prevention Hotline
1-800-273-8255

(Spanish) National Suicide Prevention Hotline
888-624-9454

Crisis Text Line
Text ‘HOME’ to 741-741

Staff Member Name *

Staff Member Email Address *

Student First Name *

Student Last Name *

Student ID Number (if possible)

Student Grade Level *

Reasons for Referral *

Academic concerns (frequently neglecting to turn work in, failing when usually passing, etc.)

Mental health (depression, anxiety, stress, anger issues)

College/career help

Suicidal thoughts

Home/family issues (suspected or actual)

Confidence/self-esteem

Conflict w/ teacher, student, or administrator

Grief/loss

Abuse/neglect (suspected or actual)

Other:

Required

Rate the level of your situation's emergency on a scale of 1-5, with 1 being the least emergent and 5 being the most emergent. *

Need to talk but not an emergency

Big emergency with possible medical help needed

Please briefly describe the referral situation. *

Submit

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