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2023-2024 RHS School Counseling Referral Form
Please complete the information below. After submitting this form, the counselor will contact you as soon as possible.
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* Indicates required question
Email
*
Your email
Your Name: (if you would like to remain anonymous, please type in "anonymous")
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
First and Last Name of the student you are referring (or your name if you are a student that is self-referring)
*
Your answer
Student's Grade
Choose
TK / K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
ATP
Your relationship to the student
Self
Parent/Guardian
Other Family Member
Teacher
Administrator
Other School Staff
Friend
I prefer to stay anonymous.
Other:
Clear selection
Reason for Referral (check all that apply)
Aggression
Anger Management
Anxious / Nervous
Bullying - Perpetrator
Bullying - Target
Challenging Behavior at School
College / Career Information
Daydreams / Fantasizes
Defiant
Difficulty in Peer Relationships
Disruptive
Dramatic change in behavior
Family Concerns
Grief and Loss
Impulsive / Hyperactive
Inattentive / Distracted
Lacks Energy
Lacks Motivation
Lying
Organizational Skills
Personal Hygiene
Physical Fighting
SARB
Sadness / Depression
Self Image / Self Esteem
Self-Injury (cutting, biting, burning)
Sexualized Behavior
Social Skills
Stealing
Suicidal Ideation
Withdrawn
Work Completion
Worried / Scared
Other:
Please add additional information below:
Your answer
Were these concerns discussed directly with parents/guardians?
*
Yes
No
Unknown
When would be a good time to meet with the student?
Your answer
Enter your contact information below (phone number OR email address)
Your answer
Prioritize this referral as:
*
Low (at the counselor's convenience)
Medium (as soon as possible)
High (very urgent)
Emergency. If chosen, bypass this referral contact 9-1-1 IMMEDIATELY.
Send me a copy of my responses.
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