Quick Links
Skip to main content Skip to navigation

Referral Form

Working...

Ajax Loading Image

 

Referrals to the school counselor can be made anytime throughout the school year. The link to this document can be found below. Please let us know if you have any questions.


Counseling Referral Form

 

__________________________________________________________________________________________________________________________________________

Small Group Counseling Referral Form

Jenks Southeast Elementary

2017-2018

Date: __________

Student Name:  ___________________________________________

Teacher Name:_________________________________Grade:______

Parent/Guardian Name:______________________________________

Phone Number:___________________email:_____________________

  1. Reason for referral:________________________________________________________________________
  2. Action previously taken by teacher/parent to help the student (i.e. conference, behavior management):____________________________________________________________________________
  3. What skills would you like the child to  learn: ____________________________________________________
  4. Three words to describe the student:___________________________________________________________
  5. One thing the students does well:______________________________________________________________
  6. Is the child aware of the referral:     ___yes      ____ no

 

Signature:________________________________________ Date:_______________________________________

Thank you for helping us help our students

 

Amy Berkinshaw                               Kristen Young

School Counselor                             Part-time School Counselor

299-4415 X5812                                299-4415 X5846

amy.berkinshaw@jenksps.org           kristen.young@jenksps.org