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RMS Student Referral to Counselor Form
Complete this form to refer yourself or another student for counseling intervention and support. When appropriate, a counselor may respond by email; so please check your email. The counseling team will see you once there is availability. Thank you.
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* Indicates required question
Email
*
Your email
Your Name
*
Your answer
Student Who Needs to See a Counselor (First and Last Name)
*
Your answer
Student ID Number
Your answer
Which Counselor are you requesting to see?
*
Choose
Mr. Rooney, Last Name begins with letters A-L
Mrs. Mohon, Last Name begins with M-Z
Mrs. Cheek, Crisis Counselor
What is the reason for the referral?
*
Academic Concerns/Planning
Anger
Anxiety
Cutting/Self-Injurious behaviors (let a teacher know immediately)
Family Concerns
Grief/Sadenss
Peer Conflict
Suspected Substance Use- alcohol, drugs, tobacco, etc. (if suspected under then influence, call an administrator immediately)
Suicidal Feelings, Statements, and/or Thoughts (let a teacher know immediately)
Teacher Conflict
Required
Describe the Concerning Behavior (Please Be Specific)
*
Your answer
Send me a copy of my responses.
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