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2015-2016 Individual Counseling Referral Form
North Butler Schools
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Student Name
Your answer
Date
Your answer
Grade
Your answer
Teacher
Your answer
Referral Source
student
parent
teacher
principal
Other:
Clear selection
Reason for Visit
academic
home/family
friendship/peer issue
self control
anger
divorce
grief
social skills
self esteem
Other:
Clear selection
Notes
Your answer
Submit
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