• Counseling Referral Form 7/6/2010
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    Student's Name __________________________________________________

    Parents'/Guardians' Names ______________________________________

    Teacher's Name __________________________________________________

    Grade ___________________   Date __________________________________

     

    Check the problems the child is encountering:

    ____easily upset/angry                   ____frequently tardy              ____hostile

    ____avoided by others                    ____dislikes school                 ____often sick

    ____frequent fights                         ____steals                               ____foul language

    ____attitude (doesn't care)              ____untruthful                        ____seems nervous

    ____seeks attention                        ____apparent neglect             ____withdrawn

    ____no friends                                ____suspect abuse                 ____low ability

    ____personal hygiene                       ____underachiever                 ____moody

    ____frequent absent                        ____other

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    Additional comments that would be helpful ________________________________________________________________________________________________________________

     

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