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Trivium Parent Referral Form to Counselor
Confidential Parent Form for Trivium LPC Counselor
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* Indicates required question
Email
*
Your email
Date of Referral:
*
MM
/
DD
/
YYYY
Student Name: Last Name, First Name
*
Your answer
Student Grade
Choose
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
Referring Parent/Guardian Name:
*
Your answer
Parent/Guardian Phone Number:
*
Your answer
Does your student know you are referring counseling or reaching out to the counselor?
Yes
No
Other:
Reasons for Referral
Dramatic change in behavior
Nerviousness/Anxiousness
Perfectionism
Grief/Loss
Impulsive
uncooperative with teacher
Withdrawn
Bullying *describe
Defiant/Disrepectful
Social Skills
Self-Image/Confidence
Depression/depressive tendencies *describe below
Absences/Tardiness
Negative Attitude
Family Conflict
Personal Hygiene
Adjustment
Other:
Background Info: Any background information that is important to be aware of
Your answer
School or Home Situations: Please describe any concerns you feel is important to be aware of
Your answer
Requests? Is there anything I can help you with (outside counselor referrals, setting up parent/teacher conference, permission for counselor to inform teachers of situation, etc)
Your answer
When does your child need to be seen?
ASAP
Sometime Today
Sometime This Week
Only wanted the counselor to be aware of the situation
Other:
Additional Information?
Your answer
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