Counseling Referral Form

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Please use this form to refer a student to the school counselor or school social worker. This can be a teacher referral or a student request.

Please use this referral form for students experiencing sudden or concerning changes in attendance, behavior, social skills, work habits, personal problems, or family crisis.

If you have any questions regarding this form or about services offered, please do not hesitate to ask. Thank you!

Email *

Name of person referring *

Student Name *

What Grade?

Pre K

Kindergarten

First

Second

Third

Fourth

Fifth

Date *

YYYY

Who is referring the student?

Teacher/ Admin/Counselor

Student (self advocating)

Caregiver

What strategies have you already tried?

Preferential seating

Offer a helpful tool (headphones, wiggle seat, break in the hallway)

Movement break schedule

Restorative conversation

Filled out a reflection form with the student

Goal setting conversation

Lunchtime conversation

Offer the student to write in a journal

Reinforce coping skills or problem solving skills

Stress management plan (Ask for help, sensory kit, take a break)

Positive reinforcement, praising student's progress/process)

Visual schedule

2/10 Incentive (Offer to chat with the student for 2 minutes per day for 10 days in a row)

Reinforce classroom rules

PBIS strategies (Reward chart, tally marks, bonus points,

Is there a strategy you've tried that isn't listed?

Reason For Referral (Check all that apply *

Social Skills (i.e. Immature, personal space, age appropriate talk)

Peer/Friendship Issues

Family Issues

Coping Skills

Academic Concern

Grief/Loss

Emotional (i.e. sad, depressed, angry, anxious)

Health Issues (i.e. frequent nurse visits, complains of being sick, poor hygiene, being disheveled)

Required

Other concerns/reason for referral

Level of Concern *

As soon as possible

Within the week.

Within a couple days.

Have you contacted the caregiver? *

Please enter 2-3 times that works for us to come get your student/child. *

Submit

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