School Counselor Referral Form 2023-2024

The survey will take approximately 5 minutes to complete.

This form is used to refer students to speak with Mr. Bolden. Your School Counselor will respond to referrals within 72 hours, unless there is a concern for self-harm which will be assessed immediately.
Date of Referral*

MonthDayYear
Student Name*
Parent/Guardian Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Grade Level/Homeroom Teacher*
Referred By (Your Name)*

First NameLast Name
Reason For Referral*

Nervous/AnxietyGrief/LossSadness/DepressionSelf HarmSuspected Drug/Alcohol AbuseSuicidal ThoughtsAbuse (physical, sexual, & mental)Peer Relationships (bullying, breakup)Family Relationships (divorce, incarcerated)Drastic Change In Mood/BehaviorOther
Special Education Services?

504IEPESL
Please Provide A Brief Detailed Description Of What You've Noticed*
Additional Notes
Should be Empty: