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Parent Counseling Referral Form
Parent(s) or Guardian(s) please complete one form per child. Each child will be seen as soon as possible and in the order of seriousness/urgency.
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* Indicates required question
Email
*
Your email
Student Name:
*
Your answer
Building:
*
Elementary
Intermediate
Middle School
High School
Grade:
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Your answer
Homeroom teacher or first period teacher:
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Your answer
Referred by:
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Your answer
Phone number:
*
Your answer
Relationship to child:
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Your answer
Reason for referral: check all the apply:
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Academic
Behavioral
Personal
Low Grades
Self-esteem/Confidence
Trouble With Friends
Performance/Test Anxiety
Chronic Sadness
Lack of Motivation
Dislikes School
Grief or loss issues
Possible Abuse
Anger/Hostility
Other:
Required
Briefly describe the primary problem/concern
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Your answer
Has the problem/concern been discussed at home?
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Your answer
Has the problem/concern been discussed with the teacher?
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Your answer
If so, what was the response?
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Your answer
When did the problem/concern begin?
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Within 24 hours
Within 3 days
Within 7 days
2 weeks ago
1 month ago
more than a month ago
Any physical concerns or medications related to the issue?
*
Your answer
Additional Comments
Your answer
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