Counseling Referral (Teacher/Parent/Guardian)
Please complete this confidential form if you have a social, emotional or mental health concern for one of your students.

PLEASE NOTE:
* If this form is completed outside of school hours, Mrs. Edwards will respond on the next school day.
* Completion of this form is not a substitute for contacting emergency services. If you believe this student is experiencing a mental health or other safety emergency, contact the appropriate authorities
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Email *
Your name: *
Student First Name *
Student Last Name *
Student's Grade *
Please describe your concern for this student. *
What is your level of concern for this student?   *
Low level of concern (which can be addressed in the next day or two)
High level of concern (needs the immediate attention of school mental health staff)
Is it okay for Mrs. Edwards to connect this student directly? *
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