Counselor Referral

This document is a counselor referral form from Hillside High School. It contains fields for the referring teacher's information, the student's name and grade, checkboxes to indicate the nature of the referral such as academic concerns, behavioral concerns, or attendance issues. There is also a follow up section for the counselor to document meeting with the student, contacting parents, or making additional referrals. The form aims to provide counselors with relevant information to address student needs or concerns.

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Counselor Referral

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Hillside High School Student Services

Counselor Referral

Referring Teacher/Admin.: _____________________________ Date: _

Students Name: ______________________________________________ Grade: _

Please indicate the nature of the referral to assist counselors in addressing the
students needs or concerns:
College, Scholarship, and/or Academic Concerns:
Financial Aid ________________________________________
SAT/ACT Registration ________________________________________
MTSS Referral Behavioral Concerns: (Please share
Allegations of Abuse/Neglect details as needed.)
Teenage Pregnancy ________________________________________
Bullying
________________________________________
Attendance Concerns
Grief Counseling
Conflict Resolution Other: ________________________________
Follow-Up: (To be Completed by Counselor)

Counselor: ________________ Date of Student Contact:

Individual Counseling with student

Academic
Attendance
Personal/Social
College/Career Readiness

Parent phone call to address concerns

Scheduled conference to further address concerns.
Referral for additional community resources

Additional Notes:

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________

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Counselor Referral

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Counselor Referral

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Hillside High School Student Services

Referring Teacher/Admin.: _____________________________________ Date: _________

Students Name: ____________________________________________________ Grade: _______

Counselor: ________________________ Date of Student Contact: ________

Individual Counseling with student

Parent phone call to address concerns

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Referring Teacher/Admin.: _____________________________ Date: _

Students Name: ______________________________________________ Grade: _

Counselor: ________________ Date of Student Contact: