Counseling Referral Form: Parent or Guardian

Please complete the form below. Required fields marked with an asterisk *

Today's date:*

Answer Required

Name of child:*

Answer Required

Your name:*

Answer Required

Relationship to child:*

Answer Required

The school's care team may wish to contact you to discuss your referral concerns. Please provide your contact information and the best time to reach you.

Phone:*

Number Required

Best time to contact:*

Answer Required

Who does the child live with?*

Answer Required

Biological parent(s)

Relative care

Adoptive parent(s)

Group home

Foster parent(s)

Other:

Desired language of service?*

Answer Required

English

Spanish

Other:

Does your child have an individualized education plan (IEP) or 504 Plan? *

Answer Required

Yes

IEP

504 Plan

I don't know

Area of concern:*

Please check all that apply:

Answer Required

Academic Concerns

Physical Health Concerns

Emotional/Behavioral Concerns

Social Concerns

Family Concerns

Other:

How often are these behaviors occerring?*

(e.g., several times per day; 1-2 times per week)

Answer Required

How long have you had this concern about your child?*

(e.g., several weeks, several months)

Answer Required

Describe if your child ever received any supports or interventions for this behavior in the past:*

Answer Required

To your knowledge, is your child receiving any supports or interventions for this behavior currently?*

If so, please describe, or write unknown:

Answer Required

What do you think will help your child experience success? *

Answer Required

Temecula Valley Charter

Please fix the highlighted areas below before submitting.

Counseling Referral Form: Parent or Guardian