Student Counseling Referral and Guardian Consent Form

Documents a referral to school counseling services, the reason for referral, and guardian consent to contact and support the student.

Submission Notice and Privacy Disclosure

• Who is submitting this referral?
  Select the role that best describes you.
• Privacy and consent acknowledgment
  Consent/disclosure language for PII collection.
• Submit anonymously
  If enabled, the counseling team will receive the referral without the submitter's name. Use only if your school allows anonymous submission for referrals.

Student Information

• Student full name
• Student ID
• Grade level
• School name
• Student date of birth
  Collect only if needed to match the student record.

Referral Details

• Reason for referral
• Brief summary of concern
• Urgency level
• Is there an immediate safety concern?
  If yes, follow your school's emergency and crisis response procedures.

Progressive Disclosure: Safety and Support Details

• Safety concern details
  Provide only the minimum necessary facts relevant to safety and school response.
• Support requested
• Previous supports tried
  Optional. Summarize supports already attempted, if known.

Guardian Information and Consent

• Guardian full name
• Relationship to student
• Guardian phone number
  Preferred contact number, if available.
• Guardian email
  Optional. Used only for counseling follow-up.
• Consent to contact guardian
  I consent to the school counseling team contacting me about this referral.
• Consent for counseling support
  I consent to the student receiving school counseling support as appropriate under school policy.
• Guardian signature
  Electronic signature confirming consent and acknowledgment.
• Signature date

School Follow-Up and Audit Trail

• Received by
  Auto-filled for audit trail.
• Review date
• Assigned counselor
• Follow-up status