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Edison Counseling Referral
Edison Counseling Referral
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Referral reported by:
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Reporter email:
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Student Name:
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Student ID#
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Student Grade Level:
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5th
6th
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8th
Has the student's parent/guardian been contacted?
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Description of the student's behavior:
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Urgency Level
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Level 1: See me soon!
Level 2: See me this week!
Level 3: Urgent, see me as soon as possible!
Level 4: Emergency, see me immediatly! Note: Notify the office (e.g. self-harm, threat to others, risk assessment, thoughts of suicide.)
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