Parent Referral Form/Permission Slip 2022-2023

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Parents will use this form to request School Counseling support for their child. Please provide some information to help Mrs. Fox best support your child. This will be a brief check-in to provide support with social-emotional needs to best prepare them for success in the classroom. Following the student check in, it may be decided upon that your child may benefit from individual or small group counseling. This form also serves the purpose of providing Mrs. Fox with permission to work with your student. Counseling services may be recommended by the classroom teacher or yourself. Collaboration will then take place between yourself, the school counselor, and classroom teacher to ensure these services best meet the needs of your student.

Email *

Student Name *

Building *

Hawkins

Hilton

Grade *

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

Teacher *

Area of Concern *

Behavior

Anxiety

Emotional Support

Coping Skills

Peer Relationships

Problem Solving

Work Completion

Motivation

Other:

Required

Describe the concern, with details of how it is impacting their behavior and success in the classroom. *

Please Check all the following that you understand and agree to: *

I understand that my school counselor provides school counseling services but does not provide therapy.

I acknowledge and allow for my student to receive school counselor support both in person or virtually.

I understand that my school counselor will break confidentiality if your student has thoughts of hurting themselves, thoughts of hurting others, or if someone is hurting them.

I understand that there may be additional limitations to confidentiality if meeting with their school counselor virtually, which may include unintended viewers or recipients.

Your student promises to adhere to appropriate student conduct while working with their school counselor, both in person or virtually.

If connecting virtually, I promise to provide my child with an opportunity to talk with the school counselor in a space that is free from family members, interruptions, and distractions.

I allow my student to participate in small group or individual based counseling as determined between the school counselor and student parent(s).

Required

Parent: Please type your name below stating that you have read the above disclosure statements with your child. *

Send me a copy of my responses.

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