School Counseling / Referral Forms

Caregivers: Please use the form below to refer your student to the school counselor. If your child requests to speak with the school counselor, the referral form is the best way to let me know. *Please note that I am located at two schools. In the referral form, there is a place to select which school the student attends.

Caregiver Referral Form

Staff: Please use the form below to refer a student to the school counselor. If the student requests to speak with the school counselor, the referral form is the best way to let me know. *Please note that I am located at two schools. In the referral form, there is a place to select the school in which you are employed.

Staff Referral Form

Students 3rd-5th Grade: Please use the form below to complete a self-referral. If you need to speak with the school counselor, the referral form is the best way to let me know. *Please note that I am located at two schools. In the referral form, there is a place to select which school you attend.

Student Referral Form

Students K-2nd Grade: Staff and caregivers will complete a staff/caregiver referral form on behalf of the student(s). K-2 students can also fill out a note and place in my mailbox on my office door.

The information students share with the school counselor is confidential. The student’s right to privacy is guarded as much as permitted by law, ethics, and school policy. The school counselor is obligated to break confidentiality when there is potential harm to the student or others, concern about neglect or abuse, or a court of law that requires testimony or student records.

At times, the counselor and school-based staff (teacher, social worker, principal, etc.) will need to exchange information about the student (how they are coping in class, strategies to help, etc.). All communication will take place only on a need-to-know basis.

School Counselors differ from mental health counselors in that we provide systemic support through multidimensional interventions. School counselors provide solution-focused individual counseling sessions on a short-term basis. Mental Health Counselors provide individual counseling sessions and function as long-term therapy. If you feel that your child needs long-term therapy, the school counselor can help refer you to mental health agencies in the area.