GHS Parent/Teacher School Counseling Referral Form 2023-2024
Thank you for making a school counseling referral on behalf of a student.  All referrals will be addressed within 72 hours of receiving this form.  If an emergency exists please call 911. suicide HOTLINE is 988 to speak with someone.
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Date: *
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Student Name: Full First and Last Name *
Please select the level of urgency below. *
Grade of student being referred *
Is this referral made before lunch or after lunch time? (Lunch is typically from 11:00 a.m.-1:35 p.m.) *
Name of person making this referral *
Please provide an email address and/or a valid contact number to be reached at. *
Who are you to the student or person being referred? *
Have you made a parent, guardian, or teacher contact regarding this concern? *
If yes, what was the outcome of your parent, guardian, or teacher contact? *
Description of the concern (Check all that apply) *
Concerns observed at school
Required
Other information
Home Situation (Check all that apply) *
Do you have personal information about any of the following?
Required
What actions were taken by the person prior to referring this student? *
Parent/Peers/Other relatives: Please ensure that all phone numbers and/or email addresses are updated in case the school counselor may need to contact you on behalf of the individual being referred. *
Required
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