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Parent Referral Form
Please fill out the form below if you would like your child to receive support from the counseling staff at Elmwood School.
* Indicates required question
Student Name
*
Your answer
Grade
2nd Grade
3rd Grade
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Parent/Guardian Name
*
Your answer
Teacher's Name/Homeroom
*
Your answer
Date
*
MM
/
DD
/
YYYY
Reason(s) for Referral to Counseling
*
Academic Difficulties
Anger/Frustration
Anxiety
Attention Difficulties
Depression/Sadness
Divorce
Friendships/Peer Relationships
Grief/Loss
Self-esteem
Social skills
Other:
Required
Briefly Describe your Reason for Referral
*
Your answer
Please provide the best phone number and email for us to reach you at:
*
Your answer
Submit
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