St Columba's Primary School - School Counsellor Referral Form
Tier 2 and 3 Referral Form. Please complete this form to refer a student for support from our School Counsellor. Your information will be kept confidential.
Child's Full Name
*
First Name
Last Name
Grade/Class of the Child
*
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Other
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Date of Referral
*
-
Month
-
Day
Year
Date
Name of Siblings
Referrer's Full Name
*
First Name
Last Name
Referrer's Contact Phone Number
*
Please enter a valid phone number.
Referrer's Email Address
example@example.com
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Contact Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email Address
example@example.com
Important Notice
Before submitting this form you must discuss this referral with the student's parents or guardian and also the appropriate Deputy Principal.
What does the Concerning Behaviour look like?
Internalising Behaviours
Often presents unhappy, low mood and tearful
Sleeping patterns impacting school life
Fatigue in school hours
Appears shy or timid
Many worries or fears/easily scared
Requires adult support to manage confrontation
Self-injury (cutting, hitting themselves)
Issues around food or eating
Complains of sickness, stomachaches or headaches
Not Observed
Is teased or having friendship problems
Other
Externalising Behaviours
*
Constantly out of the seat or assigned area
Inappropriate language used frequently
Fighting or physical aggression
Talking out of turn
Verbal defiance
Not following instructions
Inappropriate use of technology
Appears nervous/irritable
Not observed
Other
Academic Performance
Numeracy Level
*
Above level
At level
Below level
Unsure
Literacy Level
*
Above level
At level
Below level
Unsure
Academic Behaviours
Please indicate any academic difficulties
Reading
Spelling
Maths
Concentration/attention problems
Handwriting
How frequently do you see the concerning behaviours occur?
Once a week or less
Once a day
Multiple times a day
Multiple times per lesson
How much is the behaviour impacting the student's engagement in your learning area?
Engagement Level
*
Engaged 25% or less
Engaged 50% of their learning
Engaged 75% of their learning
Engaged 100% of their learning
Strategies tried to address concerning behaviour
Classroom based supports
Positive reinforcement
Clear expectations and rules
Visual supports
Seating arrangements
Behavioral contracts
Peer support
Other
Diagnosis
Does the student have a diagnosis?
*
Yes
No
Please advise the diagnosis and if there is an IEP is in place
Please attach the diagnosis report
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I consent to the referral of this student for mental health support services and understand the information will be handled confidentially.
*
Submit Referral
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