2019-2020 HESD School Counseling Services Referral Form

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Thank you for taking the time to complete the referral form. The more information you can provide me regarding your concerns the better I can support you and the student. If you prefer, you may submit a paper copy instead and put it in my box.

Once I receive this form, I will be in contact with you regarding potential services. If ongoing services are needed, I will provide permission to parents/guardians.

Please keep in mind that:
School Counseling is brief and solution focused, typically lasting 6-8 sessions.
Parent permission is required for all counseling services.
Not all students referred will receive school based services.

If you have any questions regarding this form or about services offered through the counseling program, please do not hesitate to ask me!

Today's Date *

YYYY

Teacher *

Student ID Number *

Referred by (if different from classroom teacher):

Moods/Behaviors

Please check all that apply

Anxious/worried

Depressed/unhappy

Eating disorder/body image concerns

Hyperactive/inattentive

Shy/withdrawn

Low self-esteem

Self-harm

Aggressive behaviors

Stealing

Other:

School Concerns

Please check all that apply

Class or school refusal

Lack of study skills

Poor classroom performance

Sleeping in class/always tired

Sudden changes in grades

Attendance

New student

Other:

Relationships

Please check all that apply

Bullying

Difficulty making friends

Poor social skills

Peer conflict

Difficulty with authority figures

Other:

Home Concerns

Please check all that apply

Illness/death in family

Family change

Suspected abuse

Suspected substance abuse

Conflict in the household

Other:

Reason for Referral (please be as specific as possible): *

Intervention taken prior to referral *

Please check all that apply

Strategies tried with child (please describe below)

Referred to office (please specify to who below i.e., nurse, AP, Principal, etc)

Parent conference

Notified parent

Collaboration with other teachers

Other:

Required

Please provide specifics from your responses above:

Submit

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