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Parent/Guardian Referral for School Counseling Services (Nokomis South)
This is a form to be filled out by parents/guardians if your'e seeking Mr. Kyle, the School Counselor to check-in with your child.
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* Indicates required question
Email Address
*
Your answer
Student Name
*
Your answer
Referring Person Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time
*
Time
:
AM
PM
Reason for Referral
*
Academic (Study Skills, Organization, Homework, Etc.)
Social Emotional (Anxiety, Behavior, Suicidal Ideation, Bullying, Withdrawn, Loneliness, Grief, Etc.)
COVID-19 Related (Need health response ASAP to COVID19 Related (email a SPPS Covid Lead Nurse at
Covid19@spps.org
for urgent needs)
Other:
Required
Your Explanation for the Referral
*
Your answer
Rate the Severity of this Issue
*
Not Urgent
1
2
3
4
5
Very Urgent
The student needs to see the school counselor
*
Right away
Sometime today
Sometime this week
I would like my child to see the school counselor
*
One time (Incidental event)
Several Individual Sessions
In a group with other students
At your discretion
Required
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