Counselling Referral Form (Balmoral School) 2023

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Please use this form to refer ākonga (rangitahi) through to the Counsellors available in school. Referrals can be made by staff, parents and children through using this online referral form. Our counsellors are Daniel and Maryam.

As this is a limited resource cases allocated will be based on need as decided by school processes. The school and our counsellor will curate all applications.

You can read our protocols here. Please make yourself familiar with these before completing this form.

Submitting this referral indicates your child is ready to engage with the counsellor.

The staff members who will see these completed forms could be the principal, SENCO and the counsellor.

Email *

Email Address *

Student Name *

Student Date of Birth *

YYYY

Referrer Name and Contact Information *

Designation of Referrer *

Date of Referral *

YYYY

Student Year Level *

Classroom *

Reason for Referral *

Self-Injury

Suicidal Ideation

Excessive daydreaming/disconnecting

Family concerns

Anxiety

Friendship

Low mood/Persisting Sadness

Grief/Loss

Withdrawn

Other: Please explain further in the next section

Further Explanation and Other Information

Best time to be away from the classroom (Mondays, Tuesdays, Wednesdays, or Thursdays) *

Please identify how immediate the concerns are currently *

Can Wait

Immediate

Send me a copy of my responses.

Submit

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