2022-23 TES Counselor Referral

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Fill out this form to be referred to the school counselor. Please note the informed consent policy in the student agenda. The counselor will receive an email notification after every submission, but email is not checked regularly after school hours.

If this is an emergency, please inform a trusted adult immediately.

Name of student being referred: *

Grade of student being referred: *

Person submitting referral: *

Please check all that apply regarding this student. *

Anger

Defiance or Aggression

Anxiety or Fearfulness

Bullying or Being Bullied

Depression/sadness

Dishonesty

Friendship concerns

Frequent absences or tardies

Family changes

Grief

Hyperactivity/Inattentiveness

Hygiene/Health

Homelessness

Incarceration of family member

Poor self-esteem

Suspected abuse and/or neglect

Other:

Required

Details of Referral (Please do not include confidential Information): *

Submit

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