k-8 Counselor Form

K-8 Concerned Student Referral

This referral is for students who wish to refer other peers. Students have the ability to leave their names or remain anonymous.
First & Last Name of Person Referring Student*

First NameLast Name
Do you wish to remain anonymous(unknown reporter)?*

YesNo
Student Name*

First NameLast Name
Teacher Name*

First NameLast Name
Grade*
Describe Your Concerns (Please be specific describing the nature of the situation):*
Behaviour and characteristics of concern*

Has not been attending classHas been consistently inattentive and/or asleep in classHas been verbally hostile and/or aggressive to teacher and or classmatesDisplays unusual degree of anxiety interpersonal or in relation to academic expectationsDisplays excessive anger and acts out aggressivelyDemeanor has changed from outgoing, involved and responsive to withdrawn and avoidantHas acknowledged that he/she is depressed and overwhelmedHas acknowledged that he/she is extremely anxious and overwhelmedIs being bulliedHas threatened self-harmHas made vague statements about wanting to be deadHas attempted self-harmOther students have expressed alarm and concern about this studentOther
Additional information regarding concern(s)*
Additional Comments*
On a scale from 1 to 5, how serious (immediate) is this concern*

1

2

3

4

5

1 is Less Serious, 5 is Very Serious
Should be Empty:

K-8 Concerned Student Referral