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Orangewood Counseling Referral - Teacher/Staff
Orangewood Counseling Referral - Teacher/Staff
Please complete the form below. Required fields marked with an asterisk *
Referral reported by:
*
Answer Required
Reporter email:
*
Answer Required
Student Name:
*
Answer Required
Student ID#
Answer Required
Student Grade Level:
*
Answer Required
TK
Kinder
1st
2nd
3rd
4th
Has the student's parent/guardian been contacted?
*
Answer Required
Yes
No
Description of the student's behavior:
*
Answer Required
Urgency Level
*
Answer Required
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.)
Confirmation Email
Confirmation Email
Email Required
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