Elementary School Counseling Student 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 to meet with the school counselor, please fill out the following form.

**PLEASE NOTE: If this is an emergency, and you want to hurt themselves or others; or if an adult is hurting you 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. Additionally, Mrs. Tegge cannot guarantee confidentiality for remote learners for several reasons: 1. Mrs. Tegge may have to call home to schedule a meeting with you and other family members may answer. 2. Family members may monitor you or your communication system during our meeting. Additionally, Mrs. Tegge has to tell someone if you disclose that you are thinking of hurting yourself or others, or if someone is hurting you or others. Finally, 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: *

today's date: *

YYYY

Your teacher:

Do you see a counselor outside of school? *

Yes

unsure

Please check you reason(s) you want to see Mrs. Tegge: *

Academic Issues (difficulties with classes, grades, attendance, teachers, etc).

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

Career/College (Planning for my future)

Required

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

How urgent is the issue? *

No rush

Very urgent

Does your teacher know? (Sometimes, classroom level difficulties can be resolved by the teacher). *

Yes

Unsure

Thank you for filling out the referral form! Mrs. Tegge will work with your teachers to schedule a time to see you.

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