Guidance Office Referral Form

A student was referred to the guidance office for counseling. The referral form indicates the student's name, age, grade, parent/guardian contact information, and reason for referral, which includes issues like sadness, family concerns, and social skills. The person making the referral provided details on actions already taken and discussions with parents. The form schedules the student's initial session with a guidance counselor and structures follow-up sessions to monitor outcomes.

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Guidance Office Referral Form

Uploaded by

Hainee Caoile-Minas

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Download as DOCX, PDF, TXT or read online on Scribd

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PRIORITY:

__LOW (Schedule when available) __HIGH (Schedule as soon as possible) __EMERGENCY (See now)

GUIDANCE OFFICE REFERRAL FORM

Date Received ______________
Student’s Name: ____________________________________________ Age: ______________________
Grade/Strand: _________________________________ Adviser: ________________________________
Parent/Guardian: _____________________________________ Contact No.:_______________________
Referred by:
__ Teacher __Parent __Self __Others:________________________

Reason for Referral-Problem/Concern related to: (Please check all that apply.)

( ) absences ( ) family concerns ( ) sadness

( ) academics ( ) fears ( ) self-image/confidence
( ) aggression/anger ( ) fighting ( ) social skills
( ) always tired ( ) grief ( ) stealing
( ) bullying ( ) hurts self ( ) swearing
( ) cries easily for age ( ) impulsive ( ) tardiness
( ) daydreams/fantasizes ( ) inattentive ( ) withdrawn
( ) defiant ( ) lying ( ) worries
( ) destruction of property ( ) motivation
( ) dramatic change in behavior ( ) nervous/anxious ( ) Others: __________________
( ) drop out risk ( ) over active
( ) easily distracted ( ) peer relationships

Client-Referral Problem/ History:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Actions taken by the person referring this student, if applicable:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you informed the parent/guardian about your concern? ( ) Yes ( ) No Date: __________________
Explain below the outcome of parent contact:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

______________________________________________
Signature over Printed Name of Person Making Referral
_______________________
Date of Referral
PRIORITY:
__LOW (Schedule when available) __HIGH (Schedule as soon as possible) __EMERGENCY (See now)

Initial date seen by the Guidance Counselor:_________________________________________________

Guidance Counselor:____________________________________________________________________
Best time to counsel the student: _________________________________________________________

Follow up session date:__________________________

Outcome:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Follow up session date:__________________________

__________________________________
Signature of Counselor over Printed Name

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Guidance Office Referral Form

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Guidance Office Referral Form

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PRIORITY:

GUIDANCE OFFICE REFERRAL FORM

( ) absences ( ) family concerns ( ) sadness

Client-Referral Problem/ History:

Initial date seen by the Guidance Counselor:_________________________________________________

Follow up session date:__________________________

Follow up session date:__________________________

Follow up session date:__________________________

Follow up session date:__________________________

Follow up session date:__________________________

Follow up session date:__________________________

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