2023-2024 Student Referral Form

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If you would like a counselor to contact your student please complete the following questions. Please remember that if this is a medical/mental health emergency to please call 911. We will receive a notification once your form is submitted.

We would also like to remind you that school counselors practice confidentiality when working with your student, everything discussed is confidential unless your student discloses that they are/plan to hurt themselves, others, or someone is hurting them (physically, emotionally, and/or sexually).

Email *

Your Name *

Student's First & Last Name according to SIS *

What is your relationship with the student you are referring? *

Parent

Legal Guardian

Family Member

Friend

Staff Member

Other:

What are your concerns regarding the student? *

Academic progress - student is not doing his/her schoolwork on regular basis

Academic problems - student is having difficulty doing work

Emotional or social concerns

I need to have a conversation with a student and would like to have a mediation meeting

Attendance/Tardies

Required

List any specific comments or issues *

I would like the counselor to: *

Speak with me about student

Observe Student

Speak with Student

Other

I understand that the school counselor may not be able to respond to this request immediately. If this is a crisis please contact emergency services at 911. I also understand that anything discussed with the school counselor or anything my student discusses with the school counselor is confidential unless I or my student discloses that they want to or are hurting themselves or others or is being hurt physically, emotionally, or/and sexually. *

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