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Liles Early Learning Academy: School Counseling Referral Form
Please fill out the following form if you would like for your child to see our School Counselor, Mrs. Simotas.
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* Indicates required question
Person filling out this form:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Parent's email:
*
Your answer
Parent's phone number
*
Your answer
Student Name/ID number:
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Your answer
Grade
*
Pre-K
Required
Reason for Referral:
*
family/home life
grief/trauma
stress/anxiety
suicide/self-harm
academic failure/success
school attitudes and behaviors
peer relationships/social skills
bullying, conflict, and harassment issues
shifts in behavior
self-esteem
new to town
check-in request
Other:
Required
Details of concern:
*
Your answer
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