School Counselling Referral Form

School Counselling Referral Form

You can use this counselling referral form to collect information about your students for counseling and for improving their well-being. Using this counselling referral form template, someone who's concerned about a student in your school will be asked a series of questions about the child's behavior. The school referral form template also showcases a Privacy and Confidentiality Disclosure section, along with a Signature field to validate the information sent by the referrer. Form Preview
School Counselling Referral Form Template | JotForm
  • Bakewell Primary School- School Counselling and Wellbeing Program Referral Form

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  • Privacy and Confidentiality Disclosure

    All information shared with the School Counsellor is confidential, meaning the child and families information will not be shared with a third party without prior parental consent. There is however limits to confidentiality.

    These limits to confidentiality include:

    - School Counsellor's like other Department of Education (DOE) staff, have certain duty of care obligations to all students. The School Counsellor is a mandatory reporter of child abuse and neglect. As specified under Part 5.1 A of the Care and Protection of Children Act 2007.

    - If the School Counsellor forms reasonable belief that the student/client is at risk of harm to themselves or others she has a duty of care to report this to a mental health service or to the police.

    - If it is disclosed to the School Counsellor that the student/client has engaged in a crime or is going to become involved in such an activity, the School Counsellor will need to contact the Police.

    Please note: We will always consult with parents prior to any information being shared with a third party such as an external agency or teacher. We will only share information with a third party if it is in your child's best interest.

    School Counsellor's are required to keep a file for each student accessing the School Counselling and Wellbeing Program. These files are kept on a secure database.

    If you have any questions in relation to Privacy or Confidentiality, please contact Bakewell Primary School on 08 8931 0487.

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