Counseling referral form

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This form is to be used by staff members or families. Counseling is private and confidential. All students who participate in counseling are protected by Iowa confidentiality laws. The only time a student's information from a counseling session can be accessed or shared is if the student is a danger to someone else, themselves, or is being threatened by someone else. Information is only shared to keep students safe from harm. Please fill out the form below carefully and with as many details as possible.

Thank you,
Columbus High School Guidance Office

Name of person making referral

Email of person making referral

Name of person you are referring to meet with the counselor

Grade of person you are making referral for

9th

10th

11th

12th

Clear selection

Please give a brief and detailed description for the reason you are referring this person to meet with the counselor.

On a scale from 1 (less serious) to 5 (serious), please rate how immediate the concern is.

Less serious

Serious

Clear selection

Submit

Clear form

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This form was created inside of Cedar Valley Catholic Schools. Report Abuse

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