Counselor's Referral Form

Parent Referral Form For Individual Counseling

Child’s Name:	Grade:
Teacher’s Name:	Date:

What is your main goal for the student you are referring? (please check or write in below)

	Academic	Personal/Social
	Complete homework	Get along with others
	Pay attention in class	Make new friends
	Use organization skills	Feel confident
	Participate during class	Speak at appropriate times
	Improve grades	Keep hands and feet to self
	Use effective study skills	Use kind words with others
	Complete classwork	Cope with family situations

Have you shared this goal with the student? ÿ Yes ÿ No

Have you shared this goal with the child’s teacher? ÿ Yes ÿ No

Anything else I should know? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------