School Counseling Referral Template
A school staff member uses this form to refer a student for counseling, share observed concerns, note urgency, and say whether a parent or guardian is aware.
When to use it
- A teacher notices a change in a student's mood or behavior.
- A staff member wants the school counselor to follow up on a concern.
- A student may need timely support and the counselor should know the urgency.
- Staff need to record whether a parent or guardian knows about the referral.
What it asks
- Your name
- Your email
- Your phone number
- Student’s name
- Student’s grade
- What is your concern?
- What have you observed?
- How urgent is this referral?
- Is the student’s parent or guardian aware of this referral?
Why it should be encrypted
Referrals can include identifiable student details and personal concerns or observations. Keep them from being read by anyone who does not need access, including SealForm.
Tips
- Ask staff to share only relevant details and avoid unnecessary sensitive information.
- Clarify what each urgency option means so referrals are consistent.
- Limit access to the form and responses to staff responsible for follow-up.