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Rivers School Counseling Referral Form
Please complete this form to connect a student with counseling services at Rivers. One of the counselors will be in touch with you within a week of receiving this form.
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* Indicates required question
Email
*
Your email
Your name:
*
Your answer
Name & grade of student whom you are referring:
*
Your answer
Your role at Rivers and/or your role in relation to this student:
*
Your answer
Please summarize your main concerns and/or reason for referral. Why are you interested in connecting this student with counseling services?
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Your answer
What, if any, intervention(s) have you tried so far?
Individual conversation with student
Communication/collaboration with student's advisor
Communication/collaboration with class deans and/or other faculty
Communication/ collaboration with student's caregiver(s)
Other:
Clear selection
What kind of support do you feel would be best for this student?
*
Introduction/ initial check-in to establish connection for support as-needed
Ongoing, consistent in-school support
Connection/referral to counseling support outside of school
Counselor to work with caregivers/family
Counselor consultation with faculty who support student
Other:
Is there anything else you would like to share?
Your answer
Please provide your contact information and today's date
Your answer
Send me a copy of my responses.
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