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UTVA School Counselor Referrals
For Parents and Teachers. All forms will be sent to the Elementary School Counselor - Emily Norton McMullin. Thank you for taking the time to help your student!
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* Indicates required question
Student Name:
*
Please list the student's last name and first initial.
Your answer
Student Number:
*
Your answer
Student Grade:
*
Choose
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Teacher:
*
Your answer
Referring Person and Relationship to Student:
*
Your answer
Why is this student being referred to the school counselor?
*
(Please include as much information as possible, especially regarding how this concern is impacting learning for the student and/or others)
Your answer
What strategies have been used to help support the student up to this point?
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Your answer
Please check all the apply:
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Student has an IEP
Student has a 504
Student has classroom accommodations in place
None of the above apply
Other:
Required
Has the parent and student been informed of this referral?
Would they agree to getting contacted by the counselor?
*
*Parent Permission for Referral is Highly Encouraged.
Referrals seem to be a little more effective when the legal guardians have been notified and agree to their student getting more help from the counselor.
Yes
No - Please consider getting permission first.
Please add any other details or helpful insight that will be useful for me to know. Thank you!
Your answer
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