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Counselor Referral Form
Please complete this form if you are requesting support from the school counselor about a student. All information is kept CONFIDENTIAL, unless someone is in danger.
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* Indicates required question
Student Name
*
Your answer
Grade
*
Choose
6
7
8
Team
*
Choose
6th grade
7th Grade - Traditional
7th grade - Looping
8th grade
Issues of Focus
*
What are the concerns of the student?
Motivation
Bullying
Divorce
Fighting
Worries
Stressed
Friendship
Peer Realtionships
Inattentive
Hyperactive
Social Skills
Personal Hygiene
Dishonesty
Absence/Truancy/Tardy
Withdrawn
Stealing
Signs of Depression
Vandalism
Anger
Death
Fears
Drugs
Other: ____________________________
Conflict Resolution
Academic concerns
Required
Target Behavior
*
I would like the student to be able to ....
Your answer
Services
What type of services does the student receive?
ECE
RTI
Gifted
Other
Clear selection
What Interventions have been put in place for this student?
Your answer
Additional Information needed to better serve the student.
Your answer
Referred by
*
Please Type your name and Contact number
Your answer
Relationship to Student
*
Parent/Guardian
Teacher or Staff Member
Family Member
Other:
Submit
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This form was created inside of Savannah Chatham Public School System.
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