Parent Referral- Counselor, I need help with...
Thank you for taking the time to fill out this form. A School Counselor is available for students, parents, faculty, and staff by appointment. As soon as I receive the form completed, I will be contacting you for more details and set up appointments. Feel free to call the school and ask to speak to the School Counselor, Connie Curtis or send me an email at  Connie.Curtis@humbleisd.net. You can also fill this form out or fill it out in paper and return it to the teacher or the front desk.
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Email *
Student Name *
Grade level and homeroom teacher *
Please check the items below that are causing the most difficulty *
Column 1
Loses temper easily
Something’s wrong, but I don’t know what
Needs resources
School issues ( e.g. attendance, grades, schoolwork, school anxiety)
Perfectionism
Relationships with friends/ peers
Relationships with adults (parents, teachers, family members)
Relationships with brother/ sisters
Feelings of negativity, discouragement, self doubt, or feels sad
Unhealthy or unsafe choices
Physically fight with students or at home
Destroy things when angry
Goes into “withdrawal” when angry
Is frequently in a bad or angry mood
Dealing with anger crying, whining, and/or pouting
Want his/her own way in games or group projects
Threatens others
Following directions
Listening
Keeping hands, objects, feet to self
Working and playing safely
Staying on task
Accepting No
Accepting feedback
Paying Attention
Asking Permission
Language
Other
Comments
I give my consent for my child to participate in Virtual Counseling Sessions and/or in person. *
I want the Counseling sessions via *
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