Name of Student:                                                                    Date:                          

Class and Teacher:                                                                                                                 

DOB:                                                                                                                           

Person Making Referral:                                           

            Name:                                     Address:                                              Phone:

Mother:                                                                                                                                                          

Father:                                                                                                                                                            

Guardian:                                                                                                                                                       

(optional)       

Signature(s):________________________________     _________________                                                        

Parental/Guardian Consent for Counselling:               Yes/No

(Mother and father required only where separated/divorced)

Principal’s Signature:                                                                                                                                                                                                                              

Reason(s) for Referral:                                                                                                                                              

____________________________________________________________________________________________________________________________________________________________________________________

Goal(s) for counselling:                                                                                                                                              

Other Information (including existing supports):                                                                                                      

__________________________________________________________________________________________

Counsellor’s Use Only

Level of Priority (Please circle):               Low       Moderate        Urgent

Follow Up:                                                                                                                                                                   __________________________________________________________________________________________