Teacher/Staff Counseling Referral Form
Once you've complete and send the form an email will be sent directly to Ms. Dominguez, Ms.Chavez, and Mr.Hernandez notifying them. The student will be added to their list of students to see. **If the presenting problem is dealing with some type of harm that qualifies as an emergency (the student being harmed by someone, the student is planning to harm someone else, or the student is self harming) secure the student then please contact the office via phone AND complete this form.If the student is being abused in any way please contact CPS immediately, you have 48 hours to report suspected or possible abuse.**
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Teacher/Staff Counseling Referral Form
Which counselor do you wish to contact?
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Mrs. Chavez
Mrs. Dominguez
Mr. Hernandez
Students Name
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First Name
Last Name
Grade Level
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7th
8th
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Referred By:
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Teacher
Name of Referrer:
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First Name
Last Name
E-mail of Referrer:
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Academic Reason for Referral
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Attendance
Underachievement (grades, tests, daily performance, etc.)
Study Skills
Organization
Homework
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Social/Emotional Reason for Referral
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Anger Management
Social Skills
Negative Attitude
Major Change in Behavior
Withdrawn/Shy
Confidence/Self Esteem
Anxiety
Uncooperative/Defiant
Family Conflict
Adjustment Issues
Grief-Loss/Death
Personal Hygiene
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The student needs to see the counselor...
As soon as possible-right away!
Sometime today or tomorrow.
Sometime this week.
Please include a short explanation of the presenting problem. (1-2 sentences)
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Submit
Should be Empty: