School Counselling Referral Form
Student's Details
*
First Name
Last Name
Year Level
*
Classroom Teacher's Name
Email
example@example.com
Parent/Guardian Email
example@example.com
Referral Source
*
Parent
Team Leader (If you're a teacher, please discuss the referral first with your Team Leader)
Principal/Assistant Principal
External Agency
External Agency Referral? Please state the organisation.
Referer's Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Best time to contact
*
Reason for the Referral
*
Mental Health Concerns
Parental Seperation/Divorce
Emotional Well-Being
Suicide/Self-Harm
Friends/Peer Relationships
Family Violence
Bullying
Learning Support/Educational Issues
Grief and Loss
Anger
Adjustment Issues
Beahavioural Concerns
Accomodation Issues
Parental/Carer Concerns
Other reason for referral (Please state below)
Please provide further information regarding this referral:
*
Desired wellbeing outcome:
*
Relevant History (Is the child on any medications? Does the child have a diagnosis? Is there a history of mental health illness within the family?)
*
Please upload any paperwork relevant to this referral
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Are any other services/organisations involved with this child or family?
*
Has the child or family had any Department of Children and Families (DCF) involvement?
*
Parent Consent? Parents will be contacted regarding this referral. Individual Counselling can only take place with parental/guardian consent.
*
Yes
No
Counsellor Feedback Required?
*
Yes
No
Unsure
Is the student aware of the referral?
*
Yes
No
Unsure
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