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School Counseling Faculty/Staff Referral Form
If there is ever an immediate safety concern for a student, please buzz the office to get a hold of a counselor or administrator first.
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* Indicates required question
Referring Adult:
*
Your answer
Student being Referred:
*
Your answer
Grade:
3rd
4th
5th
Clear selection
Reason for Referral:
*
Academic
Behavior
Personal
Required
Best time to see this student:
*
Your answer
Please provide some helpful information below by marking the behaviors you have observed regarding this student. Your input will be used to assist in developing the best possible support for this student.
*
Low grades/achievment
Lack of motivation
Frequently distracted
Incomplete assignments
Cheating
Absent often
Tardy often
Complains of frequent illness
Disruptive
Inattentive/poor concentration
Defiant
Impulsive/hyperactive
Overreacts to situations
Negative attitude
Little/no participation in class
Poor appearance/hygiene
Anger/irritabilty
Withdrawn
Nervous/anxious
Unhappy/depressed
Difficulty making friends
Frequent conflict with friends
Issues at home
Bizarre thinking/behavior
Lying
Other:
Required
What strategies have you already tried?
*
Your answer
Has the problem been discussed with his/her parent/guardian? If so, how did they respond?
*
Your answer
Any other information you'd like to share:
Your answer
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