Staff, Parent and Student referral

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This form is for WVE community members to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If the basis for your referral is to report any abuse, neglect, or intent to harm, you are required to contact the Department of Children's Services at 877-237-0004. Thank you for helping me better serve our students.

Your name *

School *

West View

Gap Creek

Other:

Students name *

Student's grade *

Reason for referral: Check all that apply *

Acheivement

Anger

Anxiety

Attendance

Attitude

Behavior

Bullyinig

Death of loved one

Depression

Dishonesty

Divorce

Fighting

Friendship

Hyperactive

Inattentiveness

Moody

Safety Concern

Self-Harm

Social Skills

Stealing

Threat to Self/Others**

OTHER- Add keyword in next question.

Required

Other reason for referral not listed.

Level of urgency *

Priority 1- Immediate attention needed- I am also informing an administrator to ensure immediate action.

Priority 2- Attention is warranted in the next few days.

Priority 3- Please add this student to your list of students to see.

Priority 4- FYI- For Your Information

Brief description of issue: *

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This form was created inside of Knox County Schools. Report Abuse

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