PYP counseling referral form - Wellspring Learning Community

PYP 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. Please note that a concern becomes problematic when the challenge is recurrent, repetitive, and is negatively affecting the student’s life.

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

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

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

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?

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?:

Send me a copy