ALL COUNSELOR REFERRAL FORMS

 

 

Counseling Referral 

Christy Wilmeth, M.S., LPC 

Ralls ISD District Counselor 

Referred by:_________________     Date:________________________ 

Who are you referring? _______________________________ 

Grade Level: _____________________________ 

Concerns: (Check all that apply) 

___Depression                         

___Anxiety 

___ADHD 

___Aggression 

___Anger 

___Stealing 

___Friendship 

___Relationships 

___ Grades/Academics 

___Family Issues 

___Grief 

___Tardy 

___Absences 

___Bullying – Is this student being bullied or is he/she bullying others? _________________ 

Other Concerns: _________________________________________________________ 

___________________________________________________________________________ 

Is there anything more I need to know about this student? __________________________ 

__________________________________________________________________________ 

 

When is a good time to visit with this student?___________________________________ 

_________________________________________________________________________ 

 

You may copy and paste this form and email to me at: 

[email protected]