DP Counselling Referral form - Wellspring Learning Community

DP Counseling Student Referral Form

*First Name

*Email

*Student's Name

*Last Name

*Email Confirm

Grade Level

Please tick the items that best describe the concerns you have regarding your student. After completion of this referral form, please submit it directly to the school counselor (CCCCounselor@wellspring.edu.lb). Please note that a concern becomes problematic when the challenge is recurrent, repetitive, and is negatively affecting the student’s life.

Learning behaviors

Frequently inattentive, daydreams

Constantly talking and/or in motion

Seldom finishes a task

Completes work only when individual attention is given

Reacts poorly to feedback

Difficulty handling frustration

Unusual or unacceptable habits which disturb teachers or peers

Performance is often erratic, sometimes alert and capable, other times not

Lacks basic study skills (time management, homework completion, etc.)

Does not come prepared to class

Other

Speech and Language/Comprehension

Minimal verbal responses

Often asks for clarification or to repeat instructions

Difficulty expressing ideas and concepts

Has difficulty understanding or following directions

Verbal responses are inappropriate to the situation

Other (Please Specify)

In what situation does the problem present itself? (Place, time, subject, teacher, etc.)

Actions Taken – what strategies have you tried to address this concern? Pre-referrals

Student’s knowledge of the referral:

Has not been discussed with the student

Student is aware of the referral

Have you discussed the concern(s) with parents?

YES

Was the student ever referred to the Learning Support department?

YES

Do you know of any other important information that the counselor needs to be aware of (Self-harm and/or suicide ideation or attempts are NECESSARY to be disclosed)?

If the counselor needs to see the student on a regular basis for individual counseling sessions, what day(s) and time would best work with your class schedule?:

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