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School Counseling Referral Form: San Onofre
Please complete this form to refer your student to see Mrs. Finkle, the School Counselor. You may contact me at
kfinkle@fuesd.org
or 949-325-6850 if you have any questions. Thank you!
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Student Name
*
Your answer
Grade
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Choose
TK/K
1
2
3
4
5
6
Teacher Name
Your answer
Parent or Guardian Name
Your answer
Parent's Preferred Language
English
Español
Other:
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Behavior, Emotional, or Social Concerns
Anxious or Worried
Attendance or Tardies
Difficulty Controlling Emotions
Difficulty with Focus or Attention
Difficulty Following Directions
Peer Conflict or Problems
Sad, Isolated, or Withdrawn
Talks about Death or Suicide
Other:
Academic Concerns
Decline in work quality
Homework Completion
Math
Reading
Study Skills (time management, organization, test-taking, note-taking)
Other:
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Outside Concerns
Death or Grief
Deployment
Divorce or Separation
Illness
Use of Drugs or Drinking
Other:
Any other important information regarding this student?
Your answer
*TEACHERS ONLY: Previous interventions attempted:
Academic Intervention
Parent Phone Call
Parent Conference
Student Conference
SST
Other:
This form was completed by
*
Teacher or Staff
Parent or Guardian
Administrator
Counselor
Your First and Last Name
*
Your answer
Thank you!
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