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Elementary Counseling Referral Form

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*Staff Name

*Student Name

*Student Grade

Behavioral Observations

Inattention: Frequently inattentive or prone to daydreaming.

Work Completion: Completes assignments only when provided with individual attention.

Feedback Response: Reacts poorly to constructive feedback; overly sensitive to the tone of others, often perceiving neutral comments as negative or critical.

Frustration Management: Struggles to handle frustration appropriately.

Disruptive Habits: Exhibits unusual or disruptive behavior that disturbs teachers or peers such as being impulsive, talkative, fidgeting, and frequently interrupting others.

Inconsistent Performance: Performance is erratic, sometimes alert and capable, other times disengaged.

Study Skills Deficiency: Lacks basic study skills such as time management and homework completion.

Unpreparedness: Frequently arrives to class unprepared.

Other Behavioral Concerns: Please specify.

Communication Challenges

Verbal Aggression: Tends to be verbally aggressive towards others, often using hostile or confrontational language.

Verbal Abuse: Engages in verbally abusive behavior towards other students, including name-calling, insults, cursing, or threats.

Inappropriate Responses: Provides verbal responses that are inappropriate for the situation, such as off-topic comments, sarcasm in serious contexts, or inappropriate humor.

Verbal Reticence: Exhibits signs of verbal shyness, such as reluctance to speak in group settings, difficulty starting conversations, or responding in very few words.

Selective Communication: Communicates well with certain individuals (teachers, students) but is noticeably withdrawn or uncooperative with others.

Other Communication Concerns: Please specify.

Social/Emotional Characteristics

Peer Relationships: Struggles to build relationships with peers.

Teacher Relationships: Has difficulty relating to teachers.

Difficulty in Conflict Resolution: Struggles to resolve conflicts, often escalating situations instead of diffusing them.

Group Work: Experiences challenges when working in groups.

Dependency: Displays dependence on others for support or guidance.

Manipulation: Manipulates others to achieve personal desires.

Turn-Taking: Refuses to take turns during activities.

Interruptions: Frequently interrupts others.

Sharing: Reluctant to share materials or belongings with others.

Control: Insists on having things done his/her own way.

Emotional Well-being: Appears unhappy or depressed.

Self-esteem: Does not seem to feel good about self.

Social Acceptance: Generally disliked by other students.

Motivation: Lacks motivation or interest in learning or doing his/her best.

Other Social/Emotional Concerns: Please specify.

Contextual Information

*In what situations does the problem present itself? (Consider place, time, subject, teacher, etc.)

Interventions and Actions Taken

*What strategies have you implemented to address these concerns? Please describe the actions you’ve taken and their outcomes.

Student Awareness

*

Not Discussed (The referral has not been discussed with the student)

Student Informed (The student is aware of the referral)

Parental Involvement

*Have you discussed the concerns with the student’s parents?

Yes

No

Previous Referrals

*Have you referred the student to the counseling department previously?

Yes

No

Additional InformationIs there any other important information the counselor should be aware of? (Consider background, home life, recent changes, etc.)

Programs

PYP Early Years-Nursery, KG1, KG2
PYP Elementary Grades 1-5
MYP Middle School Grades 6-10
DP High School Grades 11-12

Campuses

Mathaf Campus (PYP 3-12 years)
City Centre Campus (MYP, IB DP 13-19 years)

staff

Head of school
PYP coordinator
MYP coordinator
DP coordinator

Contact Us

Phone: 01-423-444

Email:

PO Box 116-2134

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WELLSPRING LEARNING COMMUNITY

Al Mathaf, Main Street| PO Box 116-2134 | Beirut, Lebanon

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