2022-2023 Reynolds Counseling Referral

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Thank you for taking the time to refer a student to the school counselor. The following information will help me understand how to best meet the needs of this student.

Please Contact Mr. Torrico (School Counselor) at oscar.torrico@oside.us or (760) 901-7262 with any questions/concerns.

Your Name *

Referred by: *

Parent

Teacher

Admin

Other

Email Address *

Student's Grade: *

Student's Name (First, Last) *

Areas of Concern: *

Anxiety/Fear/worry

Attendance/Truancy

Bullying

Divorce/ Family Change

Friendship /Social Skills

Grief

Homelessness

Inattention/Hyperactivity

Lack of Motivation/ Low mood

LGBTQ+ Issues

Anger/ Aggression

Self-Harm (cutting, hitting, etc..)

Self-Regulations

Suicidal Ideation

Understanding Boundaries

Other:

Required

Urgency (select One *

Low: This issue doesn't typically impact the student's learning. Please check-in with the student when you can.

Medium: This issue somewhat affects the student's ability to be successful in school. Please see the student within the next 1-2 weeks.

High: This issue is greatly impacting the student's ability to be successful in school. Please see the student within this week.

Required

Please describe your concern/s in further detail.

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