Staff to Counselor Referral Form 2020-2021

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This form is for staff members to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.

Email *

Your last name *

Your first name

Student's Last Name *

Student's First Name *

Student's grade (number or letter only. Ex. K or 3) *

Reason for referral: Check all that apply *

Acheivement

Anger

Anxiety

Attendance

Attitude

Behavior

Bullyinig

Death of loved one

Depression

Dishonesty

Divorce

Fighting

Friendship

Hyperactive

Inattentiveness

Moody

Safety Concern

Self-Harm

Social Skills

Stealing

Threat to Self/Others**

OTHER- Add keyword in next question.

Required

Other reason for referral not listed.

Level of urgency *

Priority 1- Immediate attention needed- I am also informing an administrator to ensure immediate action.

Priority 2- Attention is warranted in the next few days.

Priority 3- Please add this student to your list of students to see.

Priority 4- FYI- For Your Information

Brief description of issue: *

Addition Helpful Information: Please answer as many as possible. Your answers will help me address the student's issues more comprehensively.

Caregiver Information: Student lives with

Both parents

Single parent

Grandparent

Other

Unknown

Clear selection

Have you spoken to the caregiver about this situation?

Yes- If yes, please comment briefly in following question.

Clear selection

Caregiver contact comments:

Has the caregiver requested that I meet with the student?

Yes

Clear selection

Please note any interventions or strategies you have tried prior to referring:

Send me a copy of my responses.

Submit

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