💛 Counselor Referral Form 💛

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Please refer students for the following reasons:
>students are not connecting virtually
>students showing signs of distress
>witness of possible child abuse and/or domestic violence (800-540-4000 DCFS)
>BLAST referral for a college mentor
>SBMH referral or other mental health referrals
>SST referral
>IEP services/questions/concerns
>any other concern that I may be of help 💛

School *

Kettering

Mann

Fremont

Required

Teacher Name (last name only) *

Student Name (first and last name) *

How have you attempted to contact the student/family? *

phone call(s)

student email

parent email

See comment in section below

Other:

Required

Anything I need to know? Question...comment...concern...Please explain what you have already done/said and how I can be of help.

THANK YOU!!!!

I will follow up with any and all students that you add to the Google Counselor Referral Form. You may complete this GForm as many times as you need. I am glad to be of assistance. Miss you all!! :-) Yvette (((((hugs))))

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