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Elementary Counseling Referral Form
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*Обязательный вопрос
This referral will alert the school counselor during regular school hours. If this is an emergency, please call 911, the Suicide Prevention Helpline (1-800-273-8255 or text "support" to 741-741), or the Child Abuse Hotline (1-800-482-5964).
Student Name
*
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Last Name
*
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Grade
*
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PK
K
1st
2nd
3rd
4th
5th
6th
Relation to student
*
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Teacher / Staff
Parent/guardian or other family member
Student / Friend
Your name and contact information (optional but helpful)
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Reasons for referral (check all that apply)
*
Agression
Dramatic Change in Behavior
Bullying - Victim
Bullying - Bully
Self-injury (cutting, etc.)
Daydreams / fantasizes
Anger Management
Fighting
Stealing
Sexual Acting Out
Peer Relationships
Social Skills
Family Concerns
Cries Easily / Often for age
Self-Image / Self Confidence
Personal Hygiene
Lying
Hunger
Impulsive
Always Tired
Worried
Sadness
Scared
Defiant
Hyperactive
Inattentive
Disruptive
Withdrawn
Nervous/Anxious
Motivation
Academics
Study Skills
Homework Completion
Organization Skills
Grief and Loss
Clothing
Suicidal thoughts
Другое:
Обязательный вопрос
Is there anything else that you would like to share / explain about the situation?
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Форма создана в домене Carlisle School District.
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