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Guardian Referral Form
Parents/ Guardians please fill out the form below to refer your child for individual counseling or group counseling.
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* Indicates required question
Student Info
Student Name
*
Your answer
Grade/Teacher
*
Your answer
Referral Date
*
MM
/
DD
/
YYYY
Referral Priority
*
Low ( Schedule when available)
Moderate ( Sometime this week)
High (ASAP)
Check one for your referral priority
Low ( Schedule when available)
Moderate ( Sometime this week)
High (ASAP)
Check one for your referral priority
Guardian Info
Parent/Guardian Name
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Would you like to be contacted? If yes answer below:
Phone
Email
Best way to contact
Phone
Email
Best way to contact
Morning: 8am-11am
Afternoon: 11:30am-1pm
Evening: 1pm-4pm
Best time to contact
Morning: 8am-11am
Afternoon: 11:30am-1pm
Evening: 1pm-4pm
Best time to contact
Reasons for Referral
Please check all that apply to your reason for referral under the Emotions/mood, Behaviors, School Concerns, Relationships, and other concerns areas. It is not required that you fill out something in each referral area.
Emotions/Mood
Anxious/worried
Depressed/unhappy
Shy/Withdrawn
Low Self-Esteem/Negative Self-Talk
Angry/Low Frustration Tolerance
Other:
Behaviors
Hyperactive and or/ Inattentive
Aggressive
Stealing and or/Lying
Blurting out and or/ Arguing
Other:
School Concerns
Loss of interest in going to school
Poor Participation
Poor memory and/or often confused
Sudden change in performance
Student has Frequent Teacher Complaints
Other:
Relationships
Bullying or Bullied
Poor Social Skills
Frequent Conflicts
Few or no friends
Other:
Other Concerns
Illness/Death in Family
Parents Divorced/Seperated
Drug or Alcohol Abuse in the home
Homelessness/Sharing Housing
Physical Abuse
Sexual Abuse
Financial Hardship
Incarcerated Parent
New move/Frequent Moves
Other:
Interventions That Have Been Tried
Teacher Contact
Consulted with another Professional (i.e. pediatrician, therapist, health care professional)
Parental monitoring over a period of time
Conference with child
Increased Incentives
Problem Solving
Modifications/Accommodations
Other:
Clarify Concerns and Provide Background Below:
Your answer
Submit
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