- Faucett-Vestavia Elementary School
- Counseling Referral Form
-
Counseling Referral Form 7/6/2010 Open Form in Browser 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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