Parent/ Guardian School Counseling Referral

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Please complete this form providing any relevant information to best support this student. We will reach out to them as quickly as possible. If you have an urgent mental health concern please contact BestCare crisis line at (541) 323-5330 (ext. 2 after-hours).

Today's Date *

YYYY

Student's Name (First and Last) *

Grade *

6th

7th

8th

Your Name *

Relationship to Student *

Phone

Best Times to Reach Me

My Primary Concerns (check all that apply) *

Something's wrong but I don't know what

A loss (i.e. death of a person or pet, loss of friendship, parents' divorce)

Anger

Perfectionism

Relationships with friends/ peers

Relationships with siblings

How my child is treated by others

Feelings of negativity, discouragement, self-doubt

Unhealthy or unsafe choices

Study skills, grades, and schoolwork

Other

Required

This is a... *

Small Problem (please see them this week)

Medium Problem (please see them in the next few days)

Big Problem (please see them as soon as you can or by the end of the day)

Additional Comments

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