2023-2024 | Parent/Caregiver Counseling Referral
Please fill out form completely. 
  • Responses of this form will be looked at during school hours (8am - 4pm) on days school is in session.
  • If this is an EMERGENCY, school is not in session, or this form is filled outside of school time/days please refer to the Helpline by dialing 988, and in case of emergency please call 911.
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Email *
Parent/Guardian name filling out this form:
Best way to contact you:
(I.e. email address, cell phone number, home phone number, etc.)
 *
First Name of Student: *
Last Initial of Student: *
Grade Level Student is in: *
Team Student is on (if known):
 *
Pro-Time Teacher of Student (if known):
Reason for referring this student:
(Check all that apply)
 *
Required
If answered "other" above please state reason for referral or add additional information here to discuss with your student here.
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