4/26/22, 4:34 PM Wagon Wheel Elementary Counselor Referral Form

Wagon Wheel Elementary Counselor Referral Form

If you are a, student, parent/guardian, or teacher of a student who would like to make a referral
to talk to Ms. Duralde, please fill out this form to let me know a little bit about what is going on
and how I can help!

NOTE: If this is an EMERGENCY and you do not have immediate access to a counselor, please
speak to a trusted adult ASAP, call 911, or call the Suicide Prevention Lifeline: 1.800.273.8255.

* Required

1. Name *

2. Contact Information (Email and/or phone #) *

If you are a student and would like to request a visit with the school counselor, Ms.
Duralde, please fill out the following form to the best of your ability.

Referral Form:

STUDENTS NOTE: If you are a parent or teacher, please select the answer "I am NOT a student"
for each section and proceed to the next section/page.
ONLY

3. My name *

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4/26/22, 4:34 PM Wagon Wheel Elementary Counselor Referral Form

4. I am in *

Mark only one oval.

kindergarten

1st grade

2nd grade

3rd grade

4th grade

5th grade

I am not a student

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4/26/22, 4:34 PM Wagon Wheel Elementary Counselor Referral Form

5. I want to talk to you about: *

Mark only one oval.

My family/home. My friends

My feelings School/Classwork

Something Personal I am NOT a student

https://docs.google.com/forms/d/1gMteDQYU8PlcMkBVLucYspUeicsEp0nCukTj68bBscM/edit 3/7
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6. How soon do you want to see me? *

Mark only one oval.

Contact me immediately. Important, but you can contact me

as soon as possible.

Not urgent, but contact me soon. I just want to say hi, contact me
whenever you can.

Other:

I am NOT a student

https://docs.google.com/forms/d/1gMteDQYU8PlcMkBVLucYspUeicsEp0nCukTj68bBscM/edit 4/7
4/26/22, 4:34 PM Wagon Wheel Elementary Counselor Referral Form

Referral If you are a parent or guardian and would like to make a referral for your student,
please fill out the following form to the best of your ability. If you are a student, fill out
Form: STAFF the first two questions and ignore the rest.
AND
PARENTS
ONLY

7. I am *

Mark only one oval.

Parent/Guardian

Teacher

Administrator

School staff member

Other:

8. What is your student's first and last name? *

9. What grade is your child in?

Mark only one oval.

TK

Kindergarten

1st

2nd

3rd

4th

5th

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10. Reason for referral. Please check all that apply.

Check all that apply.

Suspected substance abuse

Suspected suicidal ideation
Suspected threat to others
Suspected self harm
Suspected abuse
Student seems sad/withdrawn
Student is visibly emotionally upset
Behavior in class
Conflict mediation
Social concerns
Stress
Issue with peers
Academic concerns
Family issues
Anxiety
Depression
Death/Grieving
Excessive absences
Social skills
Anger Management
Low self esteem
Health
Other:

11. Please provide a brief summary of your concerns.

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12. How urgent is the matter?

Mark only one oval.

Level One: I notice something is wrong, but it's not an emergency.

Level Two: The student is visibly emotionally upset and it is important, but may be
seen as soon as possible

Level Three-The student is so visibly emotionally upset that he/she needs support
immediately, he/she is a potential harm to self, harm to others, someone is harming
him/her, or he/she knows of a threat on campus.

13. How would you like me to contact you?

Mark only one oval.

Email

Phone

Google Meet or Zoom

Other:

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 Forms

https://docs.google.com/forms/d/1gMteDQYU8PlcMkBVLucYspUeicsEp0nCukTj68bBscM/edit 7/7