Counseling Referral Form (Staff and Faculty)

Exceptions to Making a Referral

INSTANCES OF CHILD ABUSE/NEGLECT & SELF-HARM (regardless of time elapsed) HAVE BEEN OMITTED as you should follow mandated reporter protocols and begin the process of contacting Franklin County Children Services (FCCS) at 614-229-7000. Please have the following form open when making the call.

SUICIDAL THOUGHTS/FEELINGS HAVE ALSO BEEN REMOVED as you should take immediate action to ensure student safety.
Faculty and Staff Counseling Referral Form

2020-21 Academic School Year
The purpose of the referral form is to give individuals the ability to refer directly to the counseling team. Because our student sessions need to be scheduled, we are asking you to tell your students when you are referring them for counseling.

Our hope is that the students will then look for—and read and respond to—our emails attempting to schedule. During your conversation, ask students for their counselor PREFERENCE, but please make sure they know it’s not a guarantee.
Please confirm that you have consulted with the student prior to completing this referral form *

Yes No

Student response/reaction to being informed they were being referred to a counselor

	1	2	3	4	5

1 is Resistant and Guarded, 5 is Receptive and Open

Student's Name *

First Name Last Name
Student Grade Level *

Grade Level 9 Grade Level 10 Grade Level 11 Grade Level 12
Your Name (Person Referring) *

First Name Last Name
What is the area of concern? You may select more than one option *

Academics Anger Management Anxiety (known diagnosis/ongoing treatment) College/Life after graduation Conflict - Home/Family Conflict - Peer Depression (known diagnosis/ongoing treatment) Grief/Loss Loneliness/Withdrawal Matters of Identity (i.e. LGBTQ+, race, gender, etc.) Medication change Motivation (lack of) Organization Overwhelmed/Stress Sadness Substance abuse (or suspicion) - Student Substance abuse (or suspicion) - Family Time Management Worry
Additional Information (How did you become aware, student details, to your knowledge has family been contacted/made aware, etc.): *
Additional Support Services (if applicable)

CARE Referral VOLS Referral Emergency Financial Assistance (Bus pass, utilities, etc.)
Factors regarding referral (Check all that apply)

One-Time Ongoing Student downplayed issue when counseling was mentioned Student did NOT want family involvement
During your conversation, which counselor(s) did student express preference in meeting with? Please check all that apply. *

Nora ODonnell (Grade 9) Karl Rose (Grade 10) Jacci Graham (Grade 11) Michelle Gabriel (Grade 12) DeeDee Cruz (Alumni/College) No Preference
How would you (person making referral) like follow-up? (Please reach out again if follow-up seems to be taking too long or if it’s been >24 hours and student has not been contacted by a member of counseling team) *

Email Phone (add number under "other") Scheduled meeting (in-person or virtual) None Needed
Supporting Documentation

Additional documentation is not required, but may be helpful for counseling purposes if something is available (i.e. examples of work, screenshots, etc.)
Upload File

Browse Files

Cancel of
With regard to SOCIAL SERVICES/FINANCIAL ASSISTANCE, please remember that direct appeals for using the school’s emergency fund should also include an email sent directly to Binh Huynh, bhuynh@cristoreycolumbus.org

Thank you for taking the time to complete the referral form. The referral will be looked at as soon as possible.

Please click submit.
Should be Empty:

Faculty and Staff Counseling Referral Form

Supporting Documentation