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Counseling Referral Form: Self or Peer

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

Today's Date:*

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My Name:*

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My Grade:*

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My Teacher:*

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Who needs help with how they are feeling? *

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Myself

Another student at my school

The school's care team may want to contact you to understand your concerns better.*

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Yes, it's ok to contact me

No, please don't contact me

Please check the box next to the reason you or someone else need help:*

I/my friend need help with:

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my home (my family or my siblings)

a friend/another student at school

school/teacher

another problem

Confirmation Email

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