Parent Counseling Referral

Parent Referral for Student Counseling Services

Submitting this form will refer your child to Mr. Ammons, the Director of Student Support at BACS. After receiving this referral, Mr. Ammons will schedule a meeting with your child within one week's time. If this situation requires more immediate support please call BACS at (281) 332-4814 during campus office hours and ask to speak with Mr. Ammons.
Your Name*

First NameLast Name
Date*

MonthDayYear
Today's date
Your Child's Name*

First NameLast Name
Your Child'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
Is this a mental health emergency? If "Yes" please call 911 or seek support at a hospital emergency room.*

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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Parent Referral for Student Counseling Services