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Gertrudis ISD
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Santa Gertrudis School: School Counseling Referral
Santa Gertrudis School: School Counseling Referral
Please complete the form below. Required fields marked with an asterisk *
1. First Name
*
Answer Required
2. Last Name
*
Answer Required
Grade
Answer Required
3. Referred by:
*
Answer Required
Self
Friend
Teacher/Staff
Parent/Guardian
Other:
4. Reason for Referral (Check all that apply)
*
Answer Required
Stress
Friendships
Futures planning
Anxiety
Romantic Relationships
Concentration/ Impulsivity
Depression
Social Anxiety/Withdrawal
Irritability
Self-harm
Body Image
Eating Disorders
Grief/Loss
Substance use
Abuse/Neglect
Suicidal Ideation
Sleeping Difficulties
Time Management
Family issues
Teacher/student conflicts
Anger Management
5. Student ID Number if you have one.
Answer Required
6. Phone Number
Number Required
7. Email
Answer Required
8. Please describe or explain your area of concern:
Answer Required
9. Personal Submitting the Counseling Referral
Answer Required
Please Select
Parent
Teacher
Administrator
Other
10. Person making referral: Name, Phone Number, & Email
Answer Required
Today's Date
*
Answer Required
Confirmation Email
Confirmation Email
Email Required
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