Counseling Referral Form

Please complete this form if you are interested in having a student begin receiving mental health or guidance counseling services.

Todays Date MM/DD/YYYY

Student Name

Current Building Location

Current Grade Level

What type of assistance is needed? (required) Academic Concerns Check-In College and/or Career Planning Assistance Conflict Resolution/Peers Family Issue Personal Issue Scheduling and Curriculum Planning Student Safety Other

What is your relationship to the student?

Follow-up Name

Follow-up Phone Number

Follow-up Email

Is there any other information you wish to share?

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Enrollment

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