School Counseling Referral Form

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School Counseling Referral Form - Parent/Guardian

Please answer the following questions to refer a student for counseling services.

Today's Date *

YYYY

Parent/Guardian Name *

Student Name *

I am recommending this student for counseling services for support with: *

Friendships/Conflict Resolution

Mean Behavior Towards Others

Self-Esteem

Self-Control/Self-Regulation

Anger Management

Stress

Family Issues

Behavior

Study Skills

Social Skills

Grief

Other students are being unkind to student

Other:

Required

What are some of the student's strengths? *

How severe is the issue? *

Not severe at all (can wait to be seen)

Extremely severe (needs to be seen ASAP)

Is there anything else you would like me to know about your child?

Contact Me

If you would like to further discuss this concern. Please reach out to me.

Kira Fischer, School Counselor
Phone: (701) 839-7135
Email: kira.fischer@k12.nd.us
Remind: Text @u7counsel to the number 81010

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