Staff member that initiated this referral
First Name
Last Name
Staff member Signature
Student details:
Student Name
First Name
Last Name
Gender (at birth)
Male
Female
Grade / Class
Next of Kin Details
First Name
Last Name
Next of Kin Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Referral
Has the parent been informed of your concern?
Yes
No
Has the parent been informed of your referral to the counselor?
Yes
No
What seems most appropriate for this student?
Individual Counseling
Group Counseling
Meeting with family or home visit
Community resources
Other
Please Provide a brief background history regarding this student that may be important for me to know; if you know any, such as diagnosis, recent traumatic event or sensitivities.
Counseling Session Details
Counsellor Details
First Name
Last Name
Date of appointment
-
Month
-
Day
Year
Date
Intervention Plan
Telephonic Counselling
External Resource Referral
On-Site Counseling
Visit
Visit 1
Visit 2
Visit 3
Other
Focus Areas / Remarks
Outcome / Recommendation
Submit
Should be Empty: