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
Name of Referring Person
Name of the Student being referred
Grade (if known)
(to the best of your knowledge)
Please check all that apply:
Difficulty in School
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?