CONFIDENTIAL COUNSELOR REFERRAL FORM

Student’s Name _______________________________________ Grade & Sec___________________

Parent/Guardian Name __________________________________Contact Number:___________________
DOB ________________ Student lives with: __________________________________
Referred by: _____Teacher _____ Parent _____ Self _____Other

Reason(s) for Referral- Problems/Concerns related to: (Please check all that apply.)

Clarify Referral Problem / History:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

ACTIONS taken by the person referring this student, if applicable: (Please attach copies of any interventions attempted)
_________________________________________________________________________________________________
_________________________________________________________________________________________________

Have you contacted parent/guardian about your concern? Y/N Date: _______________
Explain below the outcome of parent contact:
_________________________________________________________________________________________________
_________________________________________________________________________________________________

____________________________________ _________________________
Signature of Person Making Referral Date of Referral

For Guidance Counselor: (Do not write anything below)

Date received: __________________

Date of scheduled counseling: _____________ Time: ___________
Actual date and time of counseling: ________________________ from: __________ to: __________
Follow-up Session schedule: _____________________________

Counselee/ Student’s signature: _______________________________

[ ]Dramatic change in [ ] Nervous/anxious [ ] Chews [ ] Academics
behavior [ ] Perfectionist (paper/clothes/hair) [ ] Absences
[ ] Worries [ ] Aggression/Anger [ ] Makes Odd Sounds [ ] Tardy
[ ] Daydream/fantasizes [ ] Swearing [ ] Stealing [ ] Wk habits/organization
[ ] Grief [ ] Fighting [ ] Destruction of Property [ ] Completion of
[ ] Fears [ ] Lying [ ] Sexual Acting Out Assignments/Homework
[ ] Sadness [ ] Bullying [ ] Peer Relationships [ ]Drop out risk (H.S.)
[ ] Always tired [ ] Disrespectful [ ] Social Skills [ ] Other_________
[ ] Motivation [ ] Defiant [ ] Personal Hygiene
[ ] Inattentive [ ] Hurts self [ ]Family Concerns
[ ] Withdrawn [ ] Impulsive
[ ] Cries easily for age [ ] Over Active
[ ] Self- image/confidence [ ] Easily distracted
[ ] Non-touchable/pulls
away