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School Counseling Referral Form
Please answer the following questions to refer a student for counseling services.
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* Indicates required question
Grade of Student
*
PK
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Student Name
*
Your answer
I am recommending this student for counseling services for support with:
*
Friendships/Conflict Resolution
Bullying
Self-Esteem
Self-Control/Self_Regulation
Anger Management
Stress
Family Issues
Behavior
Study Skills
Social Skills
Grief
Other:
Required
Which type of counseling do you think they would benefit from?
Individual
Group
I'm not sure
Other:
Clear selection
How severe is the issue?
Not severe at all (can wait to be seen)
1
2
3
4
5
Extremely severe (needs to be seen ASAP)
Clear selection
Submit
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