Counselor Referral Form (for Staff use)

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Counselor Referral Form (for Staff use)

Use this form for non-emergency student referrals only.

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* Indicates required question

Your Name *

Your answer

Student's Name *

Your answer

Student's Grade *

Choose

K

1

2

3

4

5

If you are a homeroom teacher, what are the best times to meet with this student?

Your answer

Reason for Referral: *

Your answer

QUESTION 10: Does the student know you are referring her/him? *

Yes

No

Submit

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