Staff Member or Parent Referral for Counseling

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Please use this form for all students you wish to refer to Mrs. Burris and Mrs. Ebert. Our SISP team consists of the school counselors, school psychologist and our school social worker. We work together to ensure the student referred will receive the most appropriate resources. This is for non-emergent situations. Contact your school counselor or the front office ASAP for emergent situations.

Your Name *

Student's Name: *

Grade Level: *

Name of Student's Homeroom Teacher *

Main Reason for Referral *

Academic

Social/Emotional

Required

I am referring this student for the following issue related to academics:

Attendance (frequently tardy or absent)

Doesn't work well in groups

Homework

Interrupts class frequently

Organization

Sleeping in class/always tired

Study Skills

Test Anxiety

Underachievement

Task avoidance

I am referring this student for counseling assistance due to the following issues related to social/emotional/behaviors:

Anger Management

Anxious/Worried

Confidence/Self-Esteem

Family Conflict

Grief/Loss/Death

Impulse control

Need Community Resources

Negative Attitude

Personal Hygiene

Sexualized Behaviors

Social Skills (Friends)

Suicidal threat or ideation - STOP! DO NOT continue this referral. Call the front office and have them locate the counselor immediately. Do not leave student alone.

Uncooperative/Defiant

Withdrawn (Shy)

N/A

Please provide details for the reason of the referral. *

Is this student involved in any specials programs (EC, 504, ESL, MTSS, AIG, etc.)? *

How urgent is this referral? *

Not Urgent

ASAP

Which strategies have already been used to help this student? *

Which communication actions have already been made to help this student? *

Conference with the student

Called parents

Consulted with another school professional

Office referral

Parent conference

Nothing

Other:

Required

Briefly describe at least 3 positive strengths that the student displays... *

What is the best time for counselor to meet with you about this student? *

If you are a parent making this referral, please include your phone number/email here. *

Any additional comments or concerns to share? *

Submit

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