2019 - 2020 Student Self-Referral Form

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Please complete this referral form for students who need counseling services. All referrals will be prioritized according to need. If this is an emergency, notify a counselor and/or administrator as soon as possible.

Email *

First Name *

Last Name *

Sex *

Male

Female

Grade *

6th grade

7th grade

8th grade

Level of Urgency *

Green - "See me whenever."

Yellow - "This is important, but, it can wait a few days."

Red - "This is an emergency, I need to see you ASAP!"

Area of Concern *

Academic ("I need help with my grades." "I'm struggling to keep up.")

Social ( "I'm struggling to balance my friendships." "I think I may get into a fight.")

Emotional ("I can't control myself when I'm angry." "I feel sad all of the time." "I can't stop feeling nervous.")

Behavioral ( "I get in trouble a lot." "I like to break rules." "I argue with adults a lot.")

Other:

Please explain your issue below: *

Send me a copy of my responses.

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