Student Referral Form

CONFIDENTIAL                                                                                                                   For Office Use Only                                                                                                                                                                         Date Sent: ____________

Date Received: ________


School Counseling Referral Form


Student’s Name: _________________________________________ Grade & Teacher:____________________

                                    First                             Last


Parent/Guardian Name: ___________________________________ Home Ph.  (____) ____________________

                                                                                                             Cell Phone  (____) ___________________


Birth Date: _______________________________            Referred by:    _______Teacher                    _____Parent   


Please select any concerns that apply:




Anxiety / Worrying


Attention / Focus




Disturbances / Changes in Sleeping or Eating


Family Changes (i.e. divorce, death, move, etc.)






Organization / Study Skills


Relationships (i.e. peer, family, teacher, or other)




Self Confidence / Self-Esteem


Social Skills


Unexplained Changes in Behavior or Mood





Please clarify referral and/or any actions taken by individual referring : __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________





At Peterstown Elementary School we offer a broad range of supportive services to assist students.  School counseling is available to help children develop positive skills.  When students work through their social and emotional concerns, they are able to devote their attention and energy to learning.  Please sign and indicate your permission preference below.  Then, please return this form to your child’s school counselor.


_____ My child has permission to participate in school counseling.

_____ My child does not have permission to participate in school counseling.


Signature of Parent/Guardian: ___________________________________________  Date: ________________