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HHES School Counselor Referral Form/ Parent Version/ 22-23
This form is for a parent/guardian to request short term counseling for issues that are impacting a student's academics or behavior at school.
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* Indicates required question
Parent's first and last name:
*
Your answer
Student's first and last name:
*
Your answer
Student's grade:
*
2nd
3rd
Required
Student's homeroom teacher:
*
Your answer
Student needs help with:
*
Controlling Anger
Teasing Others
Being Teased
Grief/Loss
Making Friends
Excessive Worry
Divorce
Lying/Dishonesty
Taking Things
Motivation
Acts of Aggression
Getting Along With Others at School
Changes at Home
Other:
Required
Parent/Guardian Phone Number or Email
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Any recent home or school changes that may be affecting the child:
*
Your answer
Please explain your concern:
*
Your answer
Health concerns/ medications taken/ receiving outside therapy?
*
Your answer
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