Counseling Referral Form (Parent Version)
Hello parent(s) and/or guardian(s) my name is Stefanie Apple, and I am the Counselor at Country Lane for the 2022-2023 school year. This form was created for any parents who have concerns about their child, and feel they would benefit from school-based counseling. Please fill out this Referral Form below.

My services include:

Individual Counseling:  This is where I will meet with students individually for about 3-4 weeks for 30/min/week on any concerns teachers/parents have (i.e. study skills, coping skills, family issues, etc.)

Group Counseling: This is where I will meet with about 2-6 students in a group setting for about 8-14 weeks for 30/min/week on a specific topic (i.e. Anxiety, Anger, Social/Friendship skills, Self-esteem, etc.).

Check-in:  This is where I will check in with students either weekly, or every other week for about 10-15 minutes to see how they are doing, how their classes are going, etc.

**School-based Counseling vs. Therapy, a clarification: As a School Counselor, I do NOT provide
Therapy Services. Although, Counseling and Therapy may be similar. School-based Counseling is
more basic and short-term, and teaches students specific skills to increase their success both at
school, and in their personal lives. Therapy refers to a more in depth interaction with clients
(students), which is typically more long-term. Students who require additional long-term
support/services may benefit more from a therapeutic standpoint, and your pediatrician should be
contacted for a referral.**
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Email *
Student's Name *
Student's Teacher *
Student's Grade *
Parent(s)/Guardian(s) Name *
I am referring my child for the reason(s) below: *
Required
Additional Information/Concerns *
Are the student's teachers aware of what is going on? *
Who does the student live with? *
Guardian's Name & Phone Number *
What type of Counseling would you suggest for your child? (Check one) *
Required
If you chose Group Counseling, which one would your child benefit from the most?  (Check one) *
Required
A copy of your responses will be emailed to the address you provided.
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