EmailMeForm
NCS School Counselor Referral
Please complete this form as thoroughly as possible. The information provided on this referral form is held completely confidential.
Date of Referral
*
MM
/
DD
/
YYYY
Name of Referring Person
First
Last
Email
Phone
###
-
###
-
####
Name of the Student being referred
*
First
Last
Grade (if known)
Priority Level
(to the best of your knowledge)
Low
Moderate
High
Please check all that apply:
Family Problems
Peer Problems
Agressive Behavior
Irregular Behavior
Drugs/Alcohol
Difficulty in School
Depressed/Unhappy
Recent Traumatic Event in Life
Other (please be sure to explain below)
Please explain the situation you are concerned about. Try to provide as many details as possible to help us efficiently serve the student.
*
Would you like the counselor to contact you for more information?
Yes
No