Teacher/Staff Counseling Referral Form 
Dear Teachers & Staff,
Please use this form to refer students to me for counseling services for the 2023-2024 school year. I will review this form on a regular basis and determine next steps for the identified student, such as individual counseling, group counseling or parent consultation.
Thank you!
Rachel Sanchez
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Student First and Last name: *
Referring Teacher *
Reason for referral: *
Required
Please provide a brief description of your reason for referral: *
Action taken by the teacher (disciplinary, parent conference, referral to SST): *
One thing the student does especially well: *
Are parents/guardians aware of this referral? *
Required
If parents/guardians are unaware of referral, please explain why:
What is the best way for me to contact you regarding your referral? *
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