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School Counselor/Social Worker Referral
Complete the following form to refer your child to the school counselor or social worker. This is for non-emergency situations. Please contact us by phone if this is an emergency.
Andrew Wideman,
widemana@parkhill.k12.mo.us
, 816-359-5589
Kristen Galloway,
gallowayk@parkhill.k12.mo.us
, 816-359-6437
816-359-4380 (Hopewell main office)
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Parent or Guardian Name:
Your answer
Student Name:
Your answer
Classroom Teacher:
Your answer
Grade
Choose
Kindergarten
1st
2nd
3rd
4th
5th
Concern/Reason for Referral:
Academic
Social/Emotional/Behavior
Friends
Family
Other:
How urgent is this referral? (Note: contact us by phone if this is an emergency)
Not Urgent
1
2
3
4
5
Urgent
Clear selection
I would like someone to...
observe my child
contact me to discuss concerns
meet with my child individually
include my child in small group counseling
Clear selection
Email:
Your answer
Phone number:
Your answer
Preferred contact method:
Email
Phone Call
Clear selection
Preferred contact person:
Choose
No Preference
Mr. Wideman
Mrs. Galloway
Additional information (optional):
Your answer
Submit
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