Staff Referral to School Counselor 2024-2025

School Counselor Assignments:

Year 1: Samantha Bishop or Gaylene Gay
Year 2: Samantha Bishop
Year 3: Gaylene Gay

Year level

Year level Year 1 - Ms. Gay or Ms. Bishop Year 2- Ms. Bishop Year 3- Ms. Gay
Is this request an emergency (harm to self or others)?

Is this request an emergency (harm to self or others)? No Yes- If yes, please do not fill out this form. Immediately call the appropriate year level school counselor (or available counselor). If the counselor is not available, please call your grade level administrator or Corporal.
Student Name Student Name First Last
Your name Your name First Last
Student Number
Reason for referral

Reason for referral Academic Peer Personal
Brief description of why you are referring to the counselor.