EmailMeForm
Counseling Referral
Please use this form to refer students (or yourself) to the counseling office. Please be as specific as you possibly can.
You can use this form anonymously by simply not filling out the "person referring" information.
Information provided in this form is confidential.
Name of person BEING referred:
*
First
Last
Name of person referring:
First
Last
Email of person referring:
If you would like the counseling office to contact you for more information, you must provide either your email or phone number.
Phone of person referring:
###
-
###
-
####
If you would like the counseling office to contact you for more information, you must provide either your email or phone number.
Date of referral:
*
MM
/
DD
/
YYYY
Grade of person BEING referred:
*
Please select
12th
11th
10th
9th
8th
7th
Elementary
Not sure
Please check all that apply:
*
Academic Concern
Personal Concern
Spiritual Concern
College/Career Concern
Other:
If you choose Other, please be sure to give more information in the comment section!
Priority Level:
*
Please select
Low
Moderate
High
Please choose one so we can best serve the person being referred!
PLEASE EXPLAIN the situation you are concerned about. Try to provide as many details as possible to help us efficiently serve the student.
*
