Counseling Case Notes

* Required

1. Student's Name *

2. Grade Level *

Mark only one oval.

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

3. Student's teacher *

4. Date *

Example: January 7, 2019

5. Time *

Example: 8:30 AM
6. Referral Source *

Mark only one oval.

Teacher/Staff

Principal

Parent/Guardian

Student

Other:

7. Reason for meeting (check all that apply) *

Check all that apply.

Check-in
Just visiting
Friendship/Peer issue
Needed break from class
Sadness
Anger
Anxiety/Worry
Family concern
Lunch
Group
Behavior concern
Academic concern
Other:

8. Notes from Session *

9. Discuss future counseling plan if needed

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