School Counselor Referral Form

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Please complete one form per student referral. Each student will be seen as soon as possible and in the order of seriousness/urgency.

Referrals are responded to during school hours, Monday-Friday, 8am-3pm. If this is an emergency please call 911.

Thank you for your cooperation.

Abbie Stevens and Allison Baumsteiger
SVMS School Counselors

Student's Name

Grade

6th Grade

7th Grade

8th Grade

Clear selection

Your Name

Relationship to Student

Phone Number

Email address

Please check specific issues:

Something's wrong but I don't know what

Difficulty making friends

Social problem solving/conflict resolution

Impulsivity

Family problems

Anxiety

Low motivation

Poor coping skills

Poor self-esteem

Sad and unhappy

Shy and withdrawn from others

Recent death or loss

Other:

Additional information regarding concern:

Have you discussed this concern with your child's teachers?

Yes

Clear selection

Student knowledge of referral:

I have not discussed this with the student

Student is aware of the referral

Clear selection

Submit

Clear form

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