Hardeeville Elementary School

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Guidance Referral 12/21/2010
 

Guidance Referral Form

DATE _______________ AGE ______________________ GRADE ______

STUDENT'S NAME ______________________________  BIRTH DATE M___/ D ___/ Y_____

                                                                                                                               
ADDRESS __________________________________________HOMEPHONE _______________

MOTHER'S NAME_______________________________  WORK/CELL PH._________________

FATHER'S NAME _______________________________   WORK/CELL PH. _________________

STUDENT LIVES WITH _________________________________

TEACHER ________________________________ 

Is the student receiving Special Services? [ ] No [ ] Yes



Reason(s) for referral:

[ ] Motivation               [ ] Bullying                   [ ] Swearing      [ ] Stressed Concerns

[ ] Divorce                    [ ] Fighting                   [ ] Worries       [ ] Peer Relationships

[ ] Friendship                [ ] Absences                 [ ] Anger          [ ] Destruction of Property       

[ ] Dishonest                 [ ] Withdrawn               [ ] Trust           [ ] Personal Hygiene

[ ] Inattentive                [ ] Death                       [ ] Fears          [ ] Perfectionist

[ ] Hyperactive             [ ] Stealing                    [ ] Lying

[ ] Social Skills            [ ] Depression               [ ] Drugs


[ ] Other _________________________________________________________________________

Concerns________________________________________________________________________
 
REFERRED BY_______________________________________


Counseling Services: Date ____________________


Counselor's Signature _________________________________________

Notes:______________________________________________________