STUDENT COUNSELING REFERRAL FORM by gsr11269

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									                           STUDENT COUNSELING REFERRAL FORM
ATTENTION: Upon request, this form will be shown to the parent or guardian.
Student’s Name________________________Birthdate:___________Sex:____Date:_______________
School:___________________ Teacher/Advisory:_________________ Room #______ Grade:______
Parent(s) Name:_______________________ Phone #_____________ Referred by: _______________
Parent notified of Referral:    Yes___ No___                                Consent form sent: Yes___ No___
REASON FOR STUDENT REFERRAL: Briefly describe why student is being referred for counseling.
Please indicate severity of behavior, duration of behavior, and frequency of behavior.   Comments Required:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
ACADEMIC FUNCTIONING: Is the student meeting grade level standards:
Math: Yes______ No______        Language Arts: Yes_______ No_______
BACKGROUND INFORMATION – Language other than English spoken in home:_____________
Number of Siblings in home:_____ What Adults live in home:________________________________
List school support services student receives: (specify school year)
RSP__________    Counseling__________     Speech__________     ELD__________
DCFS__________     Regional Center__________     Other__________
HEALTH DATA, if relevant:_________________________________________________________
ADDITIONAL COMMENTS: (Special strengths, skills, aptitudes, etc.) Please use objective,
specific terms. Reference should be made to cumulative folder factors such as number of transfers,
group testing summary, and dramatic change in academic performance (approximate date):

Parent concerns or comments:__________________________________________________________
__________________________________________________________________________________
RESULTS OF COUNSELING / Services provided:
Assessment Date:________ Individual Dates: From:______ To:_______ # of Sessions:___________
Group: From:_______ To:________ # of Sessions: _______ Type of Group: ____________________
Behavior Plan Date: _____________________ Counseled by:_________________________________
Parent Contact: Yes___ No___ If yes – describe:__________________________________________
__________________________________________________________________________________
Comments:_________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

								
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