KMS Counselor Referral Form

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KMS Counselor Referral 23.24SY

Email *

Untitled Title

Name of Person Completing Form *

I am *

Parent

Student

Teacher

Administrator

If Parent or Student, please provide phone number.

Name of Student for Referral (Last Name, First Name) *

Student's Grade Level *

4th

5th

6th

Reason/s for Referral: *

Academic

Social

Emotional

Family or Outside School Issue

Lunch Bunch (please provide student names and homeroom teachers in next section)

Other:

Required

Lunch Bunch Guest Names (up to 5 besides you). NOTE: Any individual student may attend lunch bunch only once a month unless special arrangements are made with a counselor.

Additional Comments

For parents/guardians:

By typing my full name into this document, I am consenting for my child to speak with his/her counselor privately in person, over the phone, or via a virtual platform from today's date through the end of the school year. I have understand the role of the school counselor and the limits of confidentiality. I will email or call the school counselor if I have questions or concerns.

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