SDSA Counselor Referral 2023-2024

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Students, Parents/Guardians, Teachers:

Please fill out the information below. Mrs. Mitchell, Mrs. Sample or Mrs. Catlin Brown will be in contact with you soon to check-in.

We look forward to talking to you,

SDSA Counseling Team

Referrals will be monitored during normal school business hours 8:10 a.m. - 3:00 p.m.

***AFTER 3:00 P.M., IF YOU ARE IN NEED OF IMMEDIATE ASSISTANCE, PLEASE CONTACT DELAWARE CHILD PRIORITY RESPONSE (CPR) AT 1-800-969-4357.***

Email *

Record my email address with my response

Date of Referral *

YYYY

Student ID # *

Grade Level *

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Referral source *

Student / Self-referral

Parent / Guardian

Teacher / Staff

Reason for referral: *

Behavior

Academic

Personal/Social/Emotional

Attendance

Friendships

Family

Just need to talk / support

Other:

Description / reason for counselor referral (If applicable) *

Actions taken (check all that apply)

Phone call/meeting between family and teacher

Phone call/meeting between family and administrator

Phone call/meeting with counseling staff

Emails/ClassDojo between family and school staff

Consult with outside mental health provider

Consult with medical provider

Discipline referral and/or school consequences

Best time to meet with student while at school

Anything else we need to know? *

A copy of your responses will be emailed to .

Submit

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