PRIORITY: ___ Low (schedule when available) ___ High (schedule as soon as possible) ____ Emergency (see now)
Rev 2011
CONFIDENTIAL SCHOOL COUNSELOR REFERRAL FORM Date Received ______
Student’s Name _______________________________________ Grade & HmRm Teacher___________________
First Last
Parent/Guardian Name _________________________________________ Home Ph. (____)___________________
Work Ph. (____)______________ Cell Ph. _______________ Referred by: ___ Teacher ___ Parent
___ Self ___ Other
DOB ________________ Student lives with: __________________________________________________________
Reason(s) for Referral- Problems/Concerns related to: (Please check all that apply.)
[ ]Dramatic change in behavior
[ ] Worries
[ ] Daydream/fantasizes
[ ] Grief
[ ] Fears
[ ] Sadness
[ ] Always tired
[ ] Motivation
[ ] Inattentive
[ ] Withdrawn
[ ] Cries easily for age
[ ] Self image/confidence
[ ] Non-touchable/pulls away
[ ] Nervous/anxious
[ ] Perfectionist
[ ] Aggression/Anger
[ ] Swearing
[ ] Fighting
[ ] Lying
[ ] Bullying
[ ] Disrespectful
[ ] Defiant
[ ] Hurts self
[ ] Impulsive
[ ] Over Active
[ ] Easily distracted
[ ] Chews (paper/clothes/hair)
[ ] Makes Odd Sounds
[ ] Stealing
[ ] Destruction of Property
[ ] Sexual Acting Out
[ ] Peer Relationships
[ ] Social Skills
[ ] Personal Hygiene
[ ]Family Concerns
[ ] Academics
[ ] Absences
[ ] Tardy
[ ] Wk habits/organization
[ ] Completion of
Assignments/Homework
[ ]Drop out risk (H.S.)
[ ] Other_________
Clarify Referral Problem / History:
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ACTIONS taken by the person referring this student, if applicable: (Please attach copies of any interventions attempted)
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Have you contacted parent/guardian about your concern? Y/N Date: _______________
Explain below the outcome of parent contact:
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What other services is student receiving (Centerstone, out of school counseling, etc.)?
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_________________________________________ ______________________
Signature of Person Making Referral Date of Referral