School Counselor Referral Form 2022-2023 (Parent/Caregiver)
Thank you for reaching out to the Manitas Elementary School Counselor.  I will be reviewing and processing electronic referrals Monday-Friday 8:00 am-5:00 pm.  If this is an emergency outside of those hours, please call 911 and/or go to your local emergency room.

School Counselors differ from mental health counselors in that we provide systemic support through a multidimensional intervention, not only 1:1. School counselors provide individual, group, and classroom counseling sessions which are short-term and solution-focused. Mental Health Counselors provide individual counseling sessions and function as long term therapy.

Confidentiality- Information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about your child (how are they coping in class, strategies to help, etc.) All communication will take place only on a need-to-know basis.

E-mail transmissions may contain confidential health information that is privileged and legally protected from disclosure by the Health Insurance Portability and Accountability Act (HIPAA).  This information is intended only for the use of the individual or entity named in the email.  If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this e-mail is strictly prohibited.
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Email *
Parent/Guardian Name(s) *
Parent/Guardian Phone Number *
Student's Name *
Student's Grade *
Required
Student's Teacher *
Area(s) of Concern *
Required
Please tell me a little bit more about your concern *
What would you like to see happen?  (Please be aware that the counselor will need a signed consent to meet with your child on a regular basis or for them to be able to participate in group counseling) *
Required
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