EmailMe Form - Delta Charter Schools

Date Referral Submitted *
MM / DD / YYYY
Referred by *
Relationship to Student *
Student *
Student DOB *
MM / DD / YYYY
Grade *
Student Telephone: Home *
### - ### - ####
Cellular *
### - ### - ####
Student Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Student's Primary Language *
Parent's Primary Language *
Counseling services for this student were requested by (check all that applies) *Attach copy of student schedule and dashboard *

Check all that apply

Mother

Father

Foster Parent

Legal Guardian

Student

Principal*

School Psychologist*

Special Education*

Teacher/EC*
Reasons for Referral to Therapy *
Frequent absences and tardies
conflict with peers
separation or divorce of parent's
death of a family member/other
fidgety, difficulty concentrating
family history of substance abuse
transitions (new school, recent move, remarriage of parent)
doesn't complete/turn in work
Problems with relationships
Law enforcement/police report
anxious
defiance
physical or sexual abuse
verbal or emotional abuse
disruptive behavior
frequent suspensions
at risk of expulsion
depressed, sad, withdrawn
Foster care/ social services
Medical illness
Other*
*If other provide reason
Comments:
Has parent been contacted *
Yes
No
If yes, by whom