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School Counselor Referral Form 2023-2024
Welcome back to another new school year! It's going to be a great year! Ms. Ervin & Mrs. Yang are always here to help and support students through challenging life experiences so they can reach their fullest potentials. Please complete this form to let us know how we can support our students to have a great and successful school year.
Students: Complete this form for yourself if you want your school counselor to reach out to you.
Parents/Guardians: Complete this form if you want a school counselor to reach out to your child on specific concerns you may have.
School Staff: Complete this form if you want a school counselor to reach out to a student you have concerns about.
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I am... (choose only one from the box below)
A student
A parent/guardian
A school staff
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Name of person making this referral
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Your answer
Name of student (first & last) who needs to be seen
*
Your answer
Grade level of student
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6th grade
7th grade
8th grade
Reason (s) for making this referral: (You can check more than one box!) If other, you can type what it is next to that line.
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School (grades, organizational skills, study habits, motivation)
Feelings (anger, sadness, worry, nervous, etc...)
Home/family problems
Behaviors (bullying, self-control, decision making skills)
Friendship problems (drama, gossip, rumors)
Hygiene
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Other:
Required
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