2023-24 Referral Form

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New London School Counseling Department

This form is intended to be used when making a referral for a student to the school counselor or social worker to address social-emotional needs, academic, career readiness planning, and or any other barriers that impact a student. These referrals can be made by a student, teacher, staff member, or parent. If this is an emergency situation, please find your school counselor or another adult immediately. Please remember, school counselors and social workers do not maintain 24 hour access to their emails.

First and Last name of person filling out the form *

Is this referral for you(the person filling out the form) or someone else? *

Me, the person filling out the form

Someone else

If you are a parent or guardian filling out the form, please provide the BEST way to contact you

The FIRST and LAST name of the person you are filling out the form for *

Grade Level *

Other:

Required

Who would be the best person to contact you? *

Ms. Frazier- Elementary Social Worker grades K-6

Mrs. Hudberg- High School Counselor grades 7-12

Mrs. Hudson- District Social Worker

The problem is about.... *

Check as many as you need

Worrying about school

Worrying about home

Having trouble with another kid

Having trouble with an adult

Missing someone

Having trouble concentrating

Resource Room

Community Resources

FLC counseling referral

Scheduling

College/ CCP

Graduation

Attendance

Threat Assessment

other:

Other:

Required

After looking at the scale from 0-5 below, the size of the problem is... *

Required

*For teachers only* When is the best time to meet with this student

Any other information you want your school counselor or social worker to know?

Submit

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