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Counseling Referral Form (Teacher)
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* Indicates required question
Student Name
*
Your answer
Grade Level/Teacher
*
Your answer
Referred by:
*
Your answer
Date
*
MM
/
DD
/
YYYY
Reasons for referral:
*
Looks sad or depressed
Makes negative comments about self
Doesn't complete classwork/homework
Have difficulty following instructions/directions
exhibits inappropriate classroom/hall/school behavior
Has trouble getting along with others
Makes negative comments about home
Has bruises/cuts/burns
Acts tired and sleepy
Has poor attendance
Is sick often
Change in behavior
change in social skills
Other:
How long have you had this concern?
Today
Few days
One week
Two weeks or more
Clear selection
Any additional concerns or information:
Your answer
Has this issue been discussed with the student's parent/guardian?
Choose
Yes
No
If yes, when was the last date of parent contact?
MM
/
DD
/
YYYY
Please rate the severity of this referral.
*
Less Serious
1
2
3
4
5
6
7
8
9
10
Very serious
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