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Family Request for School Counseling Services
Use this form for non-emergency referrals only for students in Grades 2/3. If your student is in grade K/1, use Mrs. Young's form:
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* Indicates required question
Email
*
Your email
Your email
*
Your answer
Is if possible someone is in immediate danger?
*
Yes= Do NOT use this form. Call 911 or seek help immediately.
No
Parent/Guardian Last name
*
Your answer
Parent/Guardian First Name
*
Your answer
Parent/Guardian Phone Number (list all good contact numbers)
*
Your answer
Preferred Form of Contact
*
Email
Phone
No repy needed
Student Last Name
Your answer
Student First Name
*
Your answer
Student Grade (If K/1, use the form on Mrs. Young's Page)
*
2
3
Teacher's Last Name
*
Your answer
Primary Concern(s)
*
Study/Work Habits
Anxiety
Attendance
Friends/Social Skills
Economic Hardship
Grief/Loss
Family
Student is concernece about a classmate/peer
Other:
Required
Additional Information
Your answer
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