School Counselor Referral Form
Thank you for taking the time to fill out a referral form.

Once I receive this form, I will be in contact with you regarding potential services.

Please keep in mind that:
School counseling is  brief and solution- focused ( 6-8 sessions)
Parent Permission required for some counseling services
Not all students referred will receive school- based services
If you believe a student is being abused or neglected, please contact CPS as soon as possible, within 48 hours, in order to be in compliance with Mandated Reporter Laws. (800) 827-8724

If you have any questions, don't hesitate to ask me!
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Email *
Date *
MM
/
DD
/
YYYY
Referred by: *
I am requesting that the school counselor talk with student:
Student name: *
Grade *
Required
Has the student had an IST?
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Teacher:
Social/emotional reason(s) for referral
Academic reason(s) for referral
Have you notified the parents of these concerns?
Prior interventions implemented by teacher: (see https://www.pbisworld.com/tier-1/ for more resources)
Clear selection
What is your goal for this student?
Comments:
Submit
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