School Counselor Referral

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Please use this form to request for school counseling services. I will respond ASAP.

Student's Name *

Teacher's Name *

Who is making the referral? *

student

teacher

parent/guardian

Other:

Level of Concern: *

Level 1 - TOP PRIORITY. This is an emergency, I need help TODAY! (ex: student in in crisis - suicide threats, danger to self/others, can't reach admin, severe and unusual behavior), I tried to call but you did not answer, and I need you to speak to the child right away.

Level 2 - mid level priority. It's not an emergency, but it's been an on going occurrence, I've already used my Tier 1 interventions, parents are aware....I just need some additional support to help my student.

Level 3 - low level priority. I have a concern that I would love for you address within the next 2-3 business days.

Reason for referral: *

Preferred method of communication? *

In person

Phone Call

Google Meet

E-mail

Other:

Is there any additional information that would better help me serve the students' needs?

Submit

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