Parent Referral Form 2022-2023

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This form is for parents/guardians to request counseling services for their student. 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 urged to contact the Department of Children's Services at 877-237-0004. Thank you for helping us better serve our students.
Hannah Kincaid
Samantha McKnight

Email *

Student's First and Last Name *

Grade Level *

1st

2nd

Required

Teachers Name *

What category best describes your child's need? *

Personal/Social Matters

Academic Support

Stress/Anxiety

Behavior Management

Anger Management

Family Change (move, divorce, separation, death, new baby)

Other

Required

Please share in a few sentences any background information that initiated this referral. *

I would like the school counselor to *

consult with parent/guardian

arrange parent conference

meet with my child

none of the above. I just want the school counselor to be aware of the situation.

Parent/Guardian name *

Please provide the best way to reach you. (Ex. provide telephone number or email) *

Is there anything else you need the school counselor to know?

Submit

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

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