Teacher/ Staff Referral Form 2020-2021
Thank you for reaching out to your school counselor. Be aware that I do not check email except during school hours. If this is a crisis or emergency call 911 or go to your local emergency room.

School Counselors differ from mental health counselors in that we provide systemic support through a multidimensional intervention, not 1:1. School counselors provide individual, group, and classroom counseling sessions as short term and solution-focused. Mental Health Counselors provide individual counseling sessions and function as long term therapy.

Limitations of virtual school counseling include, but are not limited to, confidentiality, access, and availability. You can read more here: https://schoolcounselor.org/asca/media/asca/PositionStatements/PS_Virtual.pdf

Confidentiality- Information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern of neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about your child (how are they coping in class, strategies to help, etc.) All communication will take place only on a need-to-know basis.

E-mail transmissions may contain confidential health information that is privileged and legally protected from disclosure by the Health Insurance Portability and Accountability Act (HIPAA).  This information is intended only for the use of the individual or entity named in the email.  If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this e-mail is strictly prohibited.
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Student's Last Name *
Student's First Name *
Grade Level and Teacher *
Name of Person making the referral *
Please provide the best way to reach you. (Ex. provide telephone number or email) *
Please share in a few sentences any background information that initiated this referral. *
Level of urgency *
Caregiver Information: Student lives with *
Have you spoken to the caregiver about this situation? *
If Yes, you have spoken with caregiver/parent, what did you discuss and what did they say? Please include their contact INFO.
Has the caregiver requested that I meet with the student?
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Please note any interventions or strategies you have tried prior to referring: *
Is there anything else you need the school counselor to know?
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