Parents, guardians, teachers, and administrators may refer a student for counseling. Counseling is part of the educational process. Therefore, students will only be required to have a consent form if they will be seen on a weekly basis. Teachers and administrators have been given referral forms. Parents/guardians may either print the following form or pick one up at the office. Parents/guardians please fill out a consent form if you want your child to receive individual or group counseling on a weekly basis. If you have any questions, feel free to call me at 398-0500.

 

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Counselor Referral

Student: __________________________   Teacher: _________________________

Brief Description of Problem: ____________________________________________

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Things I need to know: _________________________________________________

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Things you’ve tried: ____________________________________________________

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 What would be a good day and time for the counselor to call you?

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What phone number? __________________________________________________

 

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Parent’s signature                                                                                         Date

Fold & staple or place in an envelope and have your child give it to his/her teacher.