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Teacher/Staff Peer Counseling Referral Form
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* Indicates required question
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Student's Current Grade Level
*
9th Grade
10th Grade
11th Grade
12th Grade
Referring Teacher/Staff Member
*
Your answer
Help us select a Peer Counselor that will best meet the need of this student by indicating the reason(s) for the referral (OPTIONAL):
Overwhelmed
Academics (Grades)
Feeling Angry
Bullying
Friends
Anxiety
Loneliness
Self-Esteem
Social Media
Health Issues
Depression
Self-Harm
Other:
Clear selection
Please include any additional information that would be helpful for our Peer Counselor to know in advance:
Your answer
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