West Ridge Counselor Referral for Parents

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Please use this form if you would like for me to check in with your student regarding a concern you have about his/her social-emotional health. Upon receiving a completed referral by the legal parent/guardian, I will schedule a time to meet with the student ASAP.

*Reminder: School counselors provide school based counseling and not mental health therapy. If your student needs a referral to a mental health professional I will provide you additional resources.

CONFIDENTIALITY NOTICE: This electronic communication is intended only for the person(s) named in the message. Unless otherwise indicated, it contains information that is confidential, privileged and/or exempt from disclosure under applicable law. If you have received this message in error, please notify the sender of the error and delete immediately. Thank you.

Parent/Guardian's Full Name *

Parent/Guardian's Email *

Student's Full Name *

Student's Grade *

What is your primary concern? *

My child is struggling to control his/her feelings?

My child is experiencing a peer conflict.

My child is struggling in the classroom.

We have some complicated things happening at home.

Other:

Please briefly explain below. *

What is the best way to contact you? (Phone/Email) *

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