Palmview High School Counselor Referral Form
Palmview High School Counselor Referral Form Student:__________________________Grade:__________ID #:______________ Teacher Submitting Referral:_________________________Date:______________ Counselors: Alpha Distribution 9th-12th Grade J. Martinez A-Elizondo, M. J. Regalado E. Rodriguez Escalante-Hdz., Andres J. Rodriguez V. Salinas Hdz., Andrew –Ochoa, Amy V. Chapa D. Trevino Ochoa, Antonio-Salinas, Jesus A. Flores
Salinas, Joey - Z Special ED. CTE Counselor Academy Counselor
Reason for Referral or Conference Requested: Check any of the following. School Attendance Academic Concerns Possible Alcohol/Drugs Medical Self-harm/Harm others Other:
Social/Emotional Behavior-Atypical Home Environment Request Change Schedule Stress Other:
Classroom Conduct Physical Symptoms Peer Conflict Family Concerns Anxiety Other:
Teacher Comments (elaborate on above concern):
Office Use Only Date Student Seen: ________________________________________________________Time:________________ Outcome/Recommendation/Plan of Action:
Will follow up by (Date):__________________________________________________________________________ Additional Referral to: _____Nurse____Administrator____Other_________________________________________ Staff Signature:__________________________________________
Salinas, Joey - Z Special ED. CTE Counselor Academy Counselor
Reason for Referral or Conference Requested: Check any of the following. School Attendance Academic Concerns Possible Alcohol/Drugs Medical Self-harm/Harm others Other:
Social/Emotional Behavior-Atypical Home Environment Request Change Schedule Stress Other:
Classroom Conduct Physical Symptoms Peer Conflict Family Concerns Anxiety Other:
Teacher Comments (elaborate on above concern):
Office Use Only Date Student Seen: ________________________________________________________Time:________________ Outcome/Recommendation/Plan of Action:
Will follow up by (Date):__________________________________________________________________________ Additional Referral to: _____Nurse____Administrator____Other_________________________________________ Staff Signature:__________________________________________
