Professional School Counselor Referral Process Guide Page 15
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28Missouri Comprehensive Guidance and Counseling Programs: Responsive Services Component
Referral Process Module
Page 15 of 28
RESPONSIVE SERVICES: REFERRAL PROCESS
Student Self Referral Form (High School)
Name ___________________________________________.
Grade ___________________
Homeroom teacher: ____________________. Best Hour(s) to contact me: ________________
I need to talk with you about:
URGENT!!! Something private right away!!!
Illness or loss of a family member or friend
A friend I am worried about
My angry feelings
Relationship(s) with friend(s)/peer(s)
Relationship(s) with adult(s) e.g., parent(s)/teacher(s)
Relationship(s) with sibling(s)
Someone is bullying me
I think I might be a bully myself
I want to feel better about myself
Saying “NO!” and “STOP IT” to friends who want me to do things I don’t want to do
My grades and schoolwork
Planning now for the future (e.g. career choices, post-secondary options)
Something else—I will tell you when I see you!
Other comments _____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Signed _______________________________________________Date __________________
Return this form to the Guidance and Counseling Office. I will contact you as soon as possible. If you
have indicated this is URGENT!! Return the form to a person in the guidance and counseling office or the
building secretary.
Missouri Comprehensive Guidance & Counseling Programs:
Linking School Success to Life Success
To ensure that the work of educators participating in this project will be available for the use of schools, the Department of Elementary
and Secondary Education grants permission for the use of this material for non-commercial purposes only.
May 2015
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