Counselor Referral - From Teacher

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Please fill out this form to refer a student to see the counselor. Please keep in mind that all documents with student information can be viewed at the request of a parent or guardian. If this student needs immediate or same day attention, please also call me at #3907 or call the office and they can radio me.

Email *

Record my email address with my response

Referring Teacher *

Student Name *

Is this a first time referral? *

First Time

Repeat Referral

Brief Description for Referral

Has the parent been notified of or requested this referral? *

Is there a best time for me to try to meet with this student?

Send me a copy of my responses.

Submit

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