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School Counseling Referral
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Student Name
*
Your answer
Teacher Name
*
Your answer
Who is the person filling out this form?
*
I am a student
I am the student's teacher
I am the parent/guardian of a student
Other:
Grade of Student
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Pre/K or Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Short summary of the problem
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