Student Counseling Referral Form

The Student Counseling Referral Form collects essential information about a student, including personal details, behavioral and emotional concerns, and family background. It also assesses previous counseling experiences and requires parental consent for further action. Recommended support options include peer support groups, one-on-one counseling, and special needs evaluations.

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Student Counseling Referral Form

Uploaded by

cristymayembalsado22

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Student Counseling Referral Form

Student Information

● Full Name: _______________________

● Age: ______ Grade: ______
● Teacher’s Name: ___________________
● School Name: ___________________
● Contact Information: ___________________

Behavioral & Emotional Concerns (Check all that apply)

☐ Struggles with Social Skills
☐ Difficulty Managing Emotions
☐ Expresses Feelings of Hopelessness
☐ Shows Signs of Depression
☐ History of Trauma
☐ Displays Aggressive Behavior
☐ Poor Academic Performance
☐ Lack of Motivation
☐ Other: ___________________

Home & Family Background

● Family Concerns (Divorce, Loss, Financial Hardship, etc.): ☐ Yes ☐ No

● Has the student experienced major life changes? ☐ Yes ☐ No

Has the Student Received Counseling Before?

☐ Yes ☐ No
If yes, provide details: ___________________

Parental Consent Required?

☐ Yes ☐ No

Copyright @ SampleForms.com
Recommended Support
☐ Peer Support Groups
☐ One-on-One Counseling
☐ Parent-Teacher Meeting
☐ Special Needs Evaluation

Signature of Referring Person: _________ Date: _

School Counselor Approval: _________ Date: _

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Student Counseling Referral Form

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Student Counseling Referral Form

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Student Counseling Referral Form

●​ Full Name: _______________________

Behavioral & Emotional Concerns (Check all that apply)​

Home & Family Background

●​ Family Concerns (Divorce, Loss, Financial Hardship, etc.): ☐ Yes ☐ No

Has the Student Received Counseling Before?​

Parental Consent Required?​

Signature of Referring Person: ___________________ Date: ___________

School Counselor Approval: ___________________ Date: ___________

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● Full Name: _______________________

Behavioral & Emotional Concerns (Check all that apply)

● Family Concerns (Divorce, Loss, Financial Hardship, etc.): ☐ Yes ☐ No

Has the Student Received Counseling Before?

Parental Consent Required?

Signature of Referring Person: _________ Date: _

School Counselor Approval: _________ Date: _