Referral for Counseling Services

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					                                         Referral for Counseling Services

STUDENT: ___________________________________Grade:______________Date__________
Completed by: _________________________________ Job Title: ________________________
Has there been parent contact? ________

Reason for Referral (include examples):______________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Please check any behaviors that apply:
_____shy, withdrawn                         _____destructive                             ___personal or home
                                                                                             problems
_____sad or upset                           _____seeks attention                         _____hyperactive

_____poor self-concept                      _____attendance problems                     _____very little
                                                                                               motivation
_____inattentive                            _____chronic illness                         _____thumb sucking

_____tense, nervous                         _____eats poorly / or overeats               _____unusual behavior
                                                                                               change
_____cries easily and often                 _____failure to socialize                    _____ suspected abuse

_____poor academic performance              _____divorce situation at home               _____steals or lies

_____does not complete schoolwork           _____death of family member/friend           _____dislikes school

_____disruptive in classroom                _____unusual fears or concerns               _____aggressive, hostile

_____ OTHER: _________________________________________________________________________________
            __________________________________________________________________________________

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1. Parent’s Names: ___________________________________________________Phone Number_________________
Family members who live in the child’s home: __________________________________________________________

2. Has this child ever been retained? ____yes   ____ no

3. Please list all special services this child is currently receiving (Speech, Resource, etc):__________________________
   ______________________________________________________________________________________________

4. Has this child ever had a psychological evaluation done? _____yes    _____no

5. Other relevant information about the child’s school experiences or about the child’s home life: __________________
   _______________________________________________________________________________________________

6. What do you hope to be achieved through counseling? ___________________________________________________
   ________________________________________________________________________________________________