School Counselor Student Referral & Intake Form
School Counselor Student Referral & Intake Form
Form teachers and parents use to refer a student to the school counselor with background on concerns, behavior, and academic impact.
Student name *
Your answer
Grade *
Your answer
Homeroom teacher *
Your answer
Date of referral
Referred by
Teacher
Parent/guardian
Administrator
Self
Peer
Nurse
Referrer name
Your answer
Referrer email
Primary reason for referral
+ 10 more questions
About this template
Form teachers and parents use to refer a student to the school counselor with background on concerns, behavior, and academic impact.
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