Counselor Referral Form

Scholar's Name: ______________________ Person Making Referral ____________________

Teacher: ______________________ Grade/Section: _________

Parent’s Name: _____________________ Phone: _____________ E-mail: ______________

Please Note:

·      School based counseling addresses only issues that affect the scholar in school, is problem solving in nature, and is only short term.

·      The school counselor is not a therapist, does not make diagnoses, and does not provide therapy. (A list of local professional therapists is available upon request.)

·      Signed consent form (by a parent/legal guardian) is required for ongoing counseling sessions.

1. Reason for referral:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

2. Have parent and teacher(s) discussed concern? What was the outcome?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

3. Possible issue(s) or circumstance(s) contributing to the referral:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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4. What strategies/techniques have you tried with the scholar, and what were the results?

___________________________________________________________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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(Use the back of the form if more room is needed.)