Middle School Counseling Referral

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Counselor-Ms. Scott (A-L)
Counselor-Ms. Shannon Figueroa (M-Z)

Your concerns are important to us and we would like to set up a time to meet. Please fill out the form and we will work to schedule a time with you during the school day.

Of note, we do not check or respond to referrals after school hours or on the weekends.

**IMPORTANT** IF YOU OR SOMEONE YOU KNOW IS IN IMMEDIATE DANGER PLEASE CONTACT EMERGENCY SERVICES-CALL 911 or 988 FOR MENTAL HEALTH CRISIS HOTLINE or 1-855-NMCRISIS (662-7474). ****

Email *

Your Name if different from student

Student ID number

Student name (Last, First) *

Are you or someone you know in imminent (immediate) danger or at risk of harm to yourself or someone else? *

Yes (Seek a trusted adult immediately and/or Call 911, contact emergency services/988 mental health crisis line)

I would like to see a counselor because *

I have a school related concern

I have a problem at home

I have a problem with a friend or peer

I just want to talk

Staff/Counselor Consult

Parent/Counselor Consult

Restorative intervention following behavioral issue/incident

Other:

Referred by: *

Self

Teacher/school staff

Parent, guardian, family member

Administration

Other:

Any other information you would like to share with counselor.

Submit

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