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Run: Student Counseling Referral and Guardian Consent Form

Use this Student Counseling Referral and Guardian Consent Form to document a school counseling referral, capture the concern clearly, and record guardian per...

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Submission Notice and Privacy Disclosure

Who is submitting this referral? (required)

Select the role that best describes you.

Privacy and consent acknowledgment (required)

Consent/disclosure language for PII collection.

Yes No N/A

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.

Yes No N/A

Student Information

Student full name (required)

Student ID

Grade level (required)

School name (required)

Student date of birth

Collect only if needed to match the student record.

Referral Details

Reason for referral (required)

Brief summary of concern (required)

Urgency level (required)

Is there an immediate safety concern? (required)

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 (required)

Relationship to student (required)

Guardian phone number

Preferred contact number, if available.

Guardian email

Optional. Used only for counseling follow-up.

Consent to contact guardian (required)

I consent to the school counseling team contacting me about this referral.

Consent for counseling support (required)

I consent to the student receiving school counseling support as appropriate under school policy.

Guardian signature (required)

Electronic signature confirming consent and acknowledgment.

Signature date (required)

School Follow-Up and Audit Trail

Received by

Auto-filled for audit trail.

Review date

Assigned counselor

Follow-up status

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Email (required)

Your name (optional)

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