School Counseling
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Parent/Guardian Referral Form 8/7/2015

Date: ____________________

School Counseling Referral Form

By Parent(s) or Guardian(s)

Student’s Name: _______                                                  Grade: _____     Homeroom: __________          

Referred by: _____________________________                          __ Phone #:____________________

Relationship to student: __________________

Reason for referral: (check all that apply)

___ Academic                      ___ Behavioral                                ___Personal  

___Low Grades/Failing        ___Self-Esteem/Confidence            ___Trouble with friends

___Test anxiety                   ___Chronic sadness                         ___Exposure to violence

___Lack of motivation          ___Anger/Hostility                            ___Possible abuse

___Dislikes school               ___Grief or loss issues

 

Briefly describe the primary problem/concern:

________________________________________________________________________

Has the problem/concern been discussed at home?                                                                     

Has the problem/concern been discussed with the teacher? ___________________     _____

If so, what was the response? ___________________________________________________  ___       

_________________________________________                 _____                                                       

When did the problem/concern begin?

Within: ___24 hours ___3 days ___7 days ___ 2 weeks ago ___1 month ago

   ___more than 1 month ago, please specify:

 

_______________________________________

Any physical concerns or medications related to the issue?                                                                                

Additional Comments:

                                                                                                                                                                            

                                                                                                                                                                             

 

            

Reason(s) for Referral- Problems/Concerns related to: (Please check all that apply.)

[ ]Dramatic change in behavior

[ ] Worries

[ ] Daydream/fantasizes

[ ] Grief

[ ] Fears

[ ] Sadness

[ ] Always tired

[ ] Motivation

[ ] Inattentive

[ ] Withdrawn

[ ] Cries easily for age

[ ] Self-image/confidence

[ ] Non-touchable/pulls away

[ ] Nervous/anxious

[ ] Perfectionist

[ ] Aggression/Anger

[ ] Swearing [ ] Fighting

[ ] Lying

[ ] Bullying

[ ] Disrespectful

[ ] Defiant

[ ] Hurts self

[ ] Impulsive

[ ] Over Active

[ ] Easily distracted

[ ] Chews (paper/clothes/hair)

[ ] Makes Odd Sounds

[ ] Stealing

[ ] Destruction of Property

[ ] Sexual Acting Out

[ ] Peer Relationships

[ ] Social Skills

[ ] Personal Hygiene

[ ]Family Concerns

[ ] Academics

[ ] Absences

[ ] Tardy

[ ] Weak habits/organization

[ ] Completion of Schoolwork

[ ]Drop out risk (H.S.)

[ ] Other_________