Student Counseling Referral Form

Student Counseling Referral Form — Form Fields

This education template includes 10 fields. Refer a student to the school counseling or mental health services office. Free to customize and use on ZenBuild.

• Referring Staff Member Name (text, required)
• Staff Email (email, required)
• Student Name (text, required)
• Student Grade or Year (text, required)
• Student ID (text, optional)
• Reason for Referral (dropdown selection, required) — options: Academic Concerns, Behavioral Issues, Emotional Distress, Family Situation, Peer Conflict, Other
• Description of Concern (long text, required)
• Urgency Level (multiple choice, required) — options: Routine, Soon (within a week), Urgent (within 24 hours)
• Has the student been informed of this referral? (checkboxes, optional) — options: Yes
• Any Prior Counseling or Interventions (long text, optional)