Counseling Referral Form

Counseling Referral Form

*Teacher's Name:


*Student's Name:


*Parent or Guardian:

*Phone Number:

Check the characteristics which generally describes the studens behavior:

Tattles about behavior of other:

Poor organization for class:

Manipulates others to do things:


Doesn't work well in groups:

Inturrupts class with noises:


Drug and/or acohol awareness:

Personal Problem:

Family Problem:

Excessive absence and/or tardiness:

With dran:

Seeks constant adult attention:

Inattentive; distracible:

Disturbs class routine:

Extreme quitness:

Verbally aggressive:

Low self-concept:

Unusual temper outburst:


*Briefly describe the specific incidents which led to the referral:

*What goal do you want this student to achieve?:

Check which actions have already been made to help the student make the needed changes in his/her behavior:

Conference with the student:

Worked with student individually:

Called parent:

Conferred with counselor:

Sent to the office:

Parent conference:


*Briefly describe at least 3 positive strengths this student displays:

Security Measure