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Counselor Referral Form |
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If you would like YOUR student to be seen by the counselor, please print out the following document and complete. This form is also available from me, the office or your student's teacher. You may turn it into me personally, to the mailbox outside of my office or to your student's teacher. I will meet with your child as soon as possible. |
Counselor Referral Form (Parent)
Classroom Teacher: _____________________
Date: ________
Parent Name: ________________ _________
I am referring _______________ for the following reason(s):
Moods/Behaviors School Concerns
__anxious/worried __homework not turned in/ completed
__depressed/unhappy __low test/assignment grades
__eating disorder/body __poor classroom performance
image concerns __sleeping in class/always tired
__hyperactivity/inattentive __sudden change in grades
__shy/withdrawn __frequently tardy or absent
__low self esteem __new student
__aggressive behaviors __ Other:_______________
__stealing _______________________
__ Other: _______________
_______________________
Relationships Home Concerns
__bullying __fighting w/ family members
__difficulty making friends __illness/death in family
__poor social skills __parents divorced/separated
__problems w/friends __suspected abuse
__boy/girl friend issue __suspected substance abuse
__Other: _______________ __Other: _______________
_______________________ _______________________
Comments: _____________________________________________________
_____________________________________________________________
