Referral for Counseling Services
This form is for concerned parents, teachers, administrators etc. who would like to refer a student to visit with a school counselor. You can refer a student for more than one reason, and as often as you want. Mrs. Melanie is the elementary school counselor and Ms. Nic is the middle school counselor. 
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Email *
Student Name: *
Grade level: *
I am this student's... *
Your Name: *
My level of concern for this student is... *
Not Urgent: See this student at some point within the next few weeks.
Urgent: See this student ASAP.
Concern for this student is regarding their... (choose all that apply)
Would you like me to call and talk with you before meeting with to student to talk more about why you are referring them? (this is highly recommended, but not necessary)
Clear selection
Anything else you'd like me to know?
Submit
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