Stokoe Counseling Referral form                                                                            (in-house for Staff and Teachers)
Hello Stoke Staff and Teachers,  
Please use this form to make a student counseling referral.  This form can be used if the parent has requested counseling or if you feel there may be a need for me to connect with the student.  I will use this form to check in with the student and family.   Please fill out as much information as you can.   THANK YOU
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Email *
Today's Date *
MM
/
DD
/
YYYY
Referral made by: *
Student Name *
Student Grade and Teacher  *
Has the parent been notified about the referral ? *
1 point
Does this student have a sibling at Stokoe that you know of?  (please include sibling name and grade if possible) *
1 point
What is the reason for the referral  (briefly explain) *
How urgent is this referral? *
Less serious, please check in when you can.
VERY Serious, Contact family as soon as possible
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