Prairie Vale Elementary School Counseling Program
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Student Referral Form
Here at Prairie Vale we aim to address not only academics, but social and emotional development in students as well. Individual and small group sessions are offered to address student concerns in the personal/social, academic, and career domains.
The purpose of groups and individual counseling is to provide education and support.
Potential areas in which children might need assistance:
Anxiety
Sadness
Difficulty getting along with others
Coping with family changes
Grief and Loss
Social Skills
Friendship Skills
Self-Control
Anger Management
New Student Transitions
Other! Anything you might see as a concern area
Please note that c
ounseling is based on a trusting relationship between counselor and student, therefore the counselor will keep information shared by the student and/or parent confidential except in certain situations in which an ethical responsibility limits confidentiality. By law and ethical standards confidentiality must be broken if:
1. The student reveals information about hurting himself/herself or another person.
2. The student reveals information about abuse or neglect.
3. If records are subpoenaed in a court of law.
If you would like to refer your student for these services, please fill out the confidential referral form below.
Please fill out the confidential form below to complete the referral process.
Teacher Referral Form
Your Name
*
First
Last
Grade You Teach
*
Kindy
1st
2nd
3rd
4th
Special Education
Specials
Other
Email
*
Child's Name
*
First
Last
Reason for Referral
*
Submit
Home
Blog
Meet the Counselor
For Teachers
Schedule & Calendar Downloads
Student Referral Form
For Parents
Contact