Counselling Referral

Students Name

Year Level Year Level 7 8 9 10 11 12

Date of Referral

Email

Position Position Principal Teacher(+Aide) Parent Community Member Other Staff Other (Please specify)

Other Position

Issues of Concern Issues of Concern Friendship Issues Organization Teacher Conflict Family Grief and Loss Stress Anxiety Depression Anger Issues Self-harming (or threats to) Suicide Risk Bullying Other (Please specify)

Other Issue of Concern

Brief Outline of the Concern - Including any safety issue

Priority of the referral Priority of the referral #1 Urgent (within 24hrs of referral) #2 Within the week #3 Within the fortnight #4 Not urgent (can be on a waiting list)

Details (please include date)