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6-8 Counseling Portal (Social & Emotional Concerns)
Teachers will submit this form for students during the 21-22 school year.
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* Indicates required question
Date of Referral
*
MM
/
DD
/
YYYY
Teacher's Name
*
Your answer
Teacher's Email Address
*
Your answer
Student's Name (Last Name, First Name)
*
Your answer
Student's Grade
*
Choose
6th
7th
8th
Social and Emotional Issues
*
Select a behavior in this section if you have noticed a shift in a student's behavior.
Choose
Withdrawn
Sad/Depressed
Loud/Obnoxious
Overly disagreeable with peers (or faculty)
Sleepy most days
Trouble managing friendships
Victim of bullying
Exhibiting bullying intimidating behavior
Lack of self-control
Not Applicable
Social and Emotional Issues
*
Select a behavior in this section if you have noticed a student battling with a particular personal issue.
Choose
Signs of possible alcohol/drug abuse
Teen parent
Change in living situation
Homelessness
Working long hours
Personal hygiene (frequent body/dirty clothes)
Not Applicable
Social and Emotional Issues
*
Select a behavior in this section if there is important or new information that should be shared with the counselor.
Choose
Teen Pregnacy
Parent/Family Death
Parent Drug Abuse
Involved in risky activities (gangs, drugs, "the wrong crowd")
Not Applicable
Additional Details
Your answer
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