Teacher School Counselor Support Referral form

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Note: Students with chronic attendance, behavior, social skills, or work habit concerns will be targeted for counseling interventions on a regular basis through data-driven methods. Refer students experiencing sudden or concerning changes, personal problems, or a family crisis using this form.

ALL BEHAVIOR AND DISCIPLINE CONCERNS, please reach out to admin.

Email *

Person making a referral

Student Name *

Reason For Referral

When does the student need to see a counselor? *

It is URGENT (the student has signs of distress, self harm or suicide ideations)

It can wait (counselors will call in the student within 48 hrs)

Support need areas: click all that apply

Academic

Social/Emotional

College/Career Exploration

Attendance

Other:

Clear selection

What interventions have you already done? Spoken to parents?

A copy of your responses will be emailed to the address you provided.

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