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Lowell Counselor Referral Form- STUDENT
This form is for students to complete and submit if they would like to talk with Ms. Bentley.
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* Indicates required question
Please put your first name.
*
Your answer
Please put your last name.
*
Your answer
What is your grade?
*
K
1
2
3
4
5
What is your teacher's name?
Your answer
Is this a crisis situation (you or someone else is in immediate danger)?
*
Yes
No
What is the main reason you need to talk with your School Counselor?
*
Home related
Friendship situation
School-work related
Other:
I understand my Counselor is available during school hours. I know to go to a trusted adult or call 911 if it is an emergency or the Counselor is unavailable or out of the building.
*
Yes
Submit
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