Caregiver Referral Form

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

Student's Last Name *

Student's First Name *

Grade Level *

What category best describes your child's need? *

Personal/Social Matters

Academic Support

Stress/Anxiety

Behavior Management

Anger Management

Family Change (move, divorce, separation, death, new baby)

Other

Required

Please share in a few sentences any background information that initiated this referral. *

I would like the school counselor to *

consult with parent/guardian

meet with my child

none of the above. I just want the school counselor to be aware of the situation.

Required

Parent/Guardian name *

Please provide the best way to reach you. (Ex. provide telephone number or email) *

Is there anything else you need the school counselor to know?

Submit

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This form was created inside of Knox County Schools. Report Abuse

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