Level of Concern:
Low
Medium
School Counselor Referral Form
High
Teachers, school staff and parents: Please complete the information below if you wish to refer a
student to see the counselor. To maintain confidentiality, please put your referral in a sealed envelope
and place in counselor’s mailbox.
Student Name________________________________ Grade______ Today’s Date_____________
Name/position of Person making referral_____________________________________________
Reason for Referral Circle appropriate area.
Academic
Career
Personal/Social
Detailed Concern:
Level of Concern:
School Counselor Referral Form
Low
Medium
High
Teachers, school staff and parents: Please complete the information below if you wish to refer a
student to see the counselor. To maintain confidentiality, please put your referral in a sealed envelope
and place in counselor’s mailbox.
Student Name________________________________ Grade______ Today’s Date_____________
Name/position of Person making referral_____________________________________________
Reason for Referral Circle appropriate area.
Academic
Career
Personal/Social
Detailed Concern:___________________________________________________________________
__________________________________________________________________