Elementary School Counseling Parent/Guardian Referral Form

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The school counselor (Mrs. Tegge) is available to talk with students or consult with parents for a variety of issues you may face throughout the school year. School counselors typically offer short-term counseling (about 3 sessions), and refer out with parent permission based on perceived parent need. If you would like for your student to meet with the school counselor, please fill out the following form.

**PLEASE NOTE: If this is an emergency, and the student is stating they want to hurt themselves or others; or if you suspect child abuse/neglect please call either 911 or report to Perry County Children Services(740) 342-3836. Requests are not processed immediately and may be reviewed up to two days following the request submission. All school personnel are mandated reporters and are obligated to report issues of suspected child abuse/neglect.**

Confidentiality notice: This form is confidential, and Mrs. Tegge will endeavor to keep the information between you, her, and the Google form collecting system. However, confidentiality cannot be guaranteed while the form is unsubmitted. Your email address will be submitted upon the completion of this form as an optional contact point for Mrs. Tegge to reach you.

Email *

Your name: *

Student's name: *

today's date: *

YYYY

preferred method(s) for Mrs. Tegge to counsel the student (check all that apply):

phone call

Zoom

Google Meet

other

Student's teacher:

Is your child currently working with a mental health professional outside the school environment? *

Yes

Does your child have an IEP? *

Yes

Unsure

Please check your reason(s) for referring your child: *

academic issues (Difficulties with class, grades, attendance, teachers, etc.)

Personal, Social, or Emotional (difficulties with friends or classmates, family issues, they have general bad feelings, something happened they may want to talk about, etc.)

Career/College (Planning for their future)

Required

Briefly explain your concerns and provide examples of the issue: *

How urgent is the issue? *

No rush

Very urgent

Have you talked with the student's teacher? (Sometimes, classroom level difficulties can be resolved by the teacher). *

Yes

Would you like to talk to Mrs. Tegge for strategies to help with the issue? *

Yes

Maybe

Phone number and/or email for Mrs. Tegge to contact the student: *

Please list several days/times (from 8:30-3:00 Monday-Friday) that Mrs. Tegge could counsel the student: *

Does the student know you are referring them? *

Yes

Is it okay for Mrs. Tegge to tell your student that you referred them? *

Yes

Send me a copy of my responses.

Submit

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