Counselor's Referral Form

 Parent Referral Form For Individual Counseling 


Child’s Name:

Teacher’s Name:Date:

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

 Complete homeworkGet along with others 
 Pay attention in classMake new friends 
 Use organization skillsFeel confident 
 Participate during classSpeak at appropriate times 
 Improve gradesKeep hands and feet to self 
 Use effective study skillsUse kind words with others 
 Complete classworkCope 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? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------