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Edison Counseling Referral
Edison Counseling Referral
Please complete the form below. Required fields marked with an asterisk *
Referral reported by:
*
Answer required for "Referral reported by:"
Reporter email:
*
Answer required for "Reporter email:"
Student Name:
*
Answer required for "Student Name:"
Student ID#
Answer required for "Student ID#"
Student Grade Level:
*
Answer required for "Student Grade Level:"
5th
6th
7th
8th
Has the student's parent/guardian been contacted?
*
Answer required for "Has the student's parent/guardian been contacted?"
Yes
No
Description of the student's behavior:
*
Answer required for "Description of the student's behavior:"
Urgency Level
*
Answer required for "Urgency Level"
Level 1: See me soon!
Level 2: See me this week!
Level 3: Urgent, see me as soon as possible!
Level 4: Emergency, see me immediatly! Note: Notify the office (e.g. self-harm, threat to others, risk assessment, thoughts of suicide.)
Confirmation Email
Confirmation Email
Answer required for "Confirmation Email"
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