Counseling/Bullying Referral Form

Wellness/Counseling Referral
**All Wellness/Counseling referrals will be sent to the site's Wellness Coach. For Academic concerns, the Wellness Coach will forward referrals to the School Counselor. All referrals for bullying BEGIN WITH ADMIN. Admin will refer to Wellness as necessary.**
Student Name:*

First NameLast Name
Person Referring Student:*

First NameLast Name
Your Email*
example@example.com
Who is referring?*

StaffStudentParentSelf
Does the student know you are making the referral?*

YesNo
Is it ok if we inform them of who made the referral?*

YesNo
What is this referral for?*

BullyingAcademic/Wellness
Do you need academic or wellness support?

For academic or mental health support, check the box next to your school site to send this referral to your School Counselor.
Select a School*

MIT Middle SchoolMIT High SchoolGriffin Middle/High School
MITA HS - Counseling Email
example@example.com
MITA MS - Counseling Email
example@example.com
GA - Counseling Email
example@example.com
Counseling Email
example@example.com
Are you or a student being bullied?

Refer directly to the school site admin. Find your school site below and insert the email into the email field.
Select a School*

MIT Middle SchoolMIT High SchoolGriffin Middle/High School
MITA HS - Bullying Email
example@example.com
MITA MS - Bullying Email
example@example.com
GA - Bullying Email
example@example.com
Bullying Email
example@example.com
Concern(click all that apply):*

AcademicSocialMental HealthSafety ConcernRestorative JusticeBullyingOther
Briefly describe reason for referral: *
Should be Empty:

Wellness/Counseling Referral