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:
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Anger |
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Anxiety / Worrying |
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Attention / Focus |
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Communication |
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Disturbances / Changes in Sleeping or Eating |
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Family Changes (i.e. divorce, death, move, etc.) |
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Feelings |
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Motivation |
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Organization / Study Skills |
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Relationships (i.e. peer, family, teacher, or other) |
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Sadness |
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Self Confidence / Self-Esteem |
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Social Skills |
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Unexplained Changes in Behavior or Mood |
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Other:
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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: ________________