REFERRAL FOR COUNSELING

 

 

Student's Name________________________________Current Date:______________________

Date of Birth:_________________Teacher:_________________________grade:____________

Home Phone:____________________________School:________________________________

Referring Person:______________________________Date Parents Contacted:______________

 

A.1. What is the problem? Describe behaviors in as much detail as possible.

Be specific!

 

 

 

 

  1. State a goal(s) you would like counseling to achieve for this student.

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  2. What has been done both in school and out of school to help this student?

    3.  

     

     

     

  3. What are the student's strengths and positive attributes?

 

 

 

 

Counselor's Report

 

 

  1. Results and comments of initial interviews to determine feasibi_lity counseling:

    2.  

     

     

     

  2. Has the student been recommended for counseling?

    3.  

     

     

     

  3. What are the goals of counseling?

    4.  

     

     

     

  4. What is the timeline for review of counseling you recommend?

 

 

 

 

F. Proposed alternatives to counseling: