Professional School Counselor Referral Process Guide Page 16
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28Missouri Comprehensive Guidance and Counseling Programs: Responsive Services Component
Referral Process Module
Page 16 of 28
RESPONSIVE SERVICES: REFERRAL PROCESS
Parent/Guardian Referral Form
A Professional School Counselor is available for students, parents, faculty and staff by appointment.
Please call (________________), stop by the counseling office, or e-mail (__________________) to
schedule an appointment.
I am requesting that the Professional School Counselor talk with my child:
___ Urgent—today!
___ As soon as possible
___ After the school counselor and I talk
Student’s Name _______________________________________________ Grade _________________
Classroom/Homeroom Teacher __________________________
Your Name _______________________________ Relationship to Student ______________________
Phone ____________________________ Best times to reach me _____________________________
Your Signature_______________________________________
Date _________________________
My child’s strengths include ___________________________________________________________
_________________________________________________________________________________
My primary concern(s) (Check all that apply):
Something’s wrong but I don’t know what
A loss (e.g. death of a person or pet, loss of a friendship, parents’ divorce)
Anger
Perfectionism
Relationships with friends/peers
Relationships with adults (parents/teachers)
Relationships with brothers/sisters
How my child is treated by others
Feelings of negativity, discouragement, self-doubt
Unhealthy or unsafe choices
Study skills, grades and schoolwork
Post-secondary options/Planning now for future
Other Concern(s)_______________________________________________________________
Additional information regarding concern(s) ______________________________________________
___________________________________________________________________________________
Return this form to Guidance and Counseling Office. I will contact you as soon as possible.
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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