Dunbar Early College High School School Counseling Referral Form

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A Professional School Counselor is available for students, parents, faculty and staff by appointment.
You may call, visit or submit this form to schedule an appointment with someone on the school counseling team.
Please note, if your matter is urgent, it is best to call the school directly.

Student's Name *

How urgent is this matter is?

What is your Relationship to the Student being referred?

Who are you referring this student to?

Mrs. Campbell

Mrs. Scarbro

Other:

Clear selection

What is the best time to reach this student?

First period

Second Period

Third Period

Fourth Period

Other:

What is the reason for your referral? *

Behavioral Issues

Grief

Emotional Difficulties

Self image/confidence

Nervous/anxious

Peer Relationships

Self Harm

Social Skills

Family Concerns

Academic Planning

Credit Check/ Graduation Eligibility

Attendance Issues

Completion of Assignments

Career Planning

Other:

Required

Additional information regarding the referral

Would you like to be contacted to offer additional information if needed?

Yes

Clear selection

Submit

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