Staff Counseling Referral

Staff Referral for Student Counseling

Submitting this form will refer a student to Mr. Ammons. After receiving this referral Mr. Ammons will schedule a meeting with the student within one week's time. If this is an emergency situation that requires attention before the end of this school day, please indicate that on the form and contact Mr. Ammons by phone [ext. 140 or cell phone (512) 809-1456]. If you are unable to contact Mr. Ammons by phone please inform your campus principal ASAP.
Your Name*

First NameLast Name
Date*

MonthDayYear
Today's date
Name of Student*

First NameLast Name
Student's Grade*
Please choose your grade level
Reason for meeting request. Please select all that apply.*

Academic ConcernsPeer RelationshipsFamily ConcernsAnxietyEmotional Well-beingSpiritual IssuesDepressionAddictionSelf-harmThey are a threat to harm othersOther
Are the student's parents aware that you are making this referral?*

YesNo
Is this an emergency situation? If "Yes" please inform Mr. Ammons or the student's campus principal ASAP.*

YesNo
Please provide any additional information that would be helpful for me to know.
Statement on Confidentiality

Confidentiality is a crucial part of the counseling relationship. However, there are limits to confidentiality, especially if there is a risk of harm to yourself or others.

Thank you for taking this step to seek support. I look forward to speaking with you.

- Mr. Ammons
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Staff Referral for Student Counseling