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Parent/Guardian/Community Counselor Referral Form
Dear School Counselor,
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* Indicates required question
Student Name:
*
Your answer
I am requesting that a school counselor talk with my child:
*
Urgent!
As soon as possible
After the school counselor and I talk
Student's Name:
*
Your answer
School Student Attenda
Crab Orchard
Highland
Hustonville
Stanford
Waynesburg
Lincoln County Middle School
Lincoln County High School
Unknown
Clear selection
Your Name:
*
Your answer
Relationship to student:
*
Your answer
Phone:
*
Your answer
Best times to reach me:
*
Your answer
Your digital signature:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
My primary concern(s) (check all that apply):
*
Something is wrong, but I don't know what it is
A loss (e.g. death of a person or pet, loss of a friendship, parents' divorce)
Anger
Pefectionism
Relationships with friends/peers
Relationships with adults (parents/teachers)
Relationships with brothers/sisters
How my child is treated by others
Feelings of negativity, discouragement
Unhealthy or unsafe choices
Academic concerns
Other concerns
Required
If "Other concerns" was checked, please list:
Your answer
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