Referrals

MindMatters Counseling

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This form is for teachers, parents, or students to refer a student to the school counselor for academic, career, or social-emotional support.

Date of referral: *

Your full name: *

Student's full name: *

Your relationship to student: *

Teacher
Parent/Guardian
Classmate
Relative
Friend

Your contact information (email/phone) : *

Student's school name: *

Student's grade/year level: *

Response time: *

Urgent
Somewhat urgent
Not urgent

Reason for referral: *

Academic concerns: *

Declining grades
Difficulty staying focused in class
Poor time management or organization
Lack of motivation or engagement

Career concerns: *

Uncertainty about future goals
Need for career exploration or planning

Social-emotional concerns: *

Anxiety or stress
Difficulty managing emotions (e.g., anger, sadness)
Peer relationship issues (e.g., conflict, bullying)
Family issues affecting school performance
Low self-esteem or confidence

Behavioral concerns: *

Disruptive behavior in class
Withdrawal from peers or activities
Frequent absences or tardiness

Crisis concerns (immediate attention required): *

Threats to self or others
Suspected abuse or neglect

Please describe concerns in more detail: *

Have any interventions already been attempted: *

Yes
No

Preferred follow-up: *

Meet with the student
Schedule a meeting with the teacher(s)
Schedule a meeting with the parent/guardian

I hereby understand and agree to acknowledge that all information shared will remain confidential, except in cases where a student’s or someone else's safety is at risk. *

I agree
I do not agree

Leave this field empty