School Counseling Referral Form 2023-2024

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Please fill out the form to give your school counselor, Mrs. Blalock, more information about your visit. **PLEASE NOTE: MS. BLALOCK WILL PRIORITIZE URGENT NEEDS (urgent means immediately!--someone is unsafe or in danger). If your need is not urgent, Ms. Blalock will meet with you as soon as she can.**

NOTE: Mrs. Blalock does not check this form or e-mails after hours or over the weekends. If this is an emergency, please find the nearest adult that can assist you, or you can access help using the following websites: https://www.saysomething.net/ or http://www.integratedfamilyservices.net/ (click top right corner to live chat with a mental health professional).

Student LAST Name *

Student FIRST Name *

Email Address *

What is your grade level? *

Grade 6

Grade 7

Grade 8

What is your concern to visit Mrs. Blalock today? *

Family

Emotional

Friends

High School/College Planning

Bullying

Conflict

Personal

Behavior

Academics (Grades)

Assistance with resources

Goal setting and organization

Provide some details regarding the above. *

How urgent is your concern? *

Urgent- See you today (for example, reporting a concern for self or classmate: self-harm, threats, crisis)

Somewhat urgent- See you today or tomorrow (personal, friend issues, etc.)

Not urgent- Meet sometime within the week (questions or concerns, academic related, etc.)

Today's Date *

YYYY

Submit

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