Republic of the Philippines

Department of Education
Region 02 (Cagayan Valley)
SCHOOLS DIVISION OFFICE OF ISABELA
CALLANGIGAN ELEMENTARY SCHOOL
QUEZON DISTRICT
Quezon, Isabela 3324

CONFIDENTIAL COUNSELOR REFERRAL FORM

Pupil’s Name _________________________________ Grade and Section ________________

Parent/Guardian Name__________________________Contact Number:_______________
DOB: ___________________ Pupil lives with: ________________________
Referred by: _______ Teacher ______ Parent _______ Self _______ Other

Reason(s) for Referral-Problems/Concerns related to: (Please check all that apply)

( ) Dramatic change in ( ) Nervous/anxious ( ) Chews paper/clothes/hair

Behavior ( ) Perfectionist ( ) Stealing
( ) Worries ( ) Aggression/Anger ( ) Destruction of Property
( ) Daydream/fantasizes ( ) Fighting ( ) Sexual Acting Out
( ) Grief ( ) Lying ( ) Peer Relations
( ) Fears ( ) Bullying ( ) Personal Hygiene
( ) Sadness ( ) Disrespectful ( ) Family Concerns
( ) Always tired ( ) Defiant ( ) Academics
( ) Motivation ( ) Hurts self ( ) Absences
( ) Inattentive ( ) Impulsive ( ) Tardy
( ) Withdrawn ( ) Aver Active ( ) Completion of assignments/Homework
( ) Cries easily for age ( ) Easily Distracted ( ) Other _________
( ) Self-image/confidence

Clarify Referral Problem/ History:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________

Actions taken by the person referring this student, if applicable:( Please attach copies of any
interventions attempted)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________

Have you contacted parent/guardian about your concern? Y/N Date: __________________
Explain below the outcome of parent contact:
____________________________________________________________________________
____________________________________________________________________________
__________________________________

_____________________________ _________________________
Signature of Person Making Referral Date of Referral

For Guidance Counselor- Designate: ( Do not write anything below)

Date received: ______________________________

Date of scheduled coaching/ mentoring: ______________ Time: _____________________
Actual Date and Time of Coaching/Mentoring: ______________ from: _______ to __________
Follow-up session schedule: __________________________

Counselee/Pupil’s Signature: __________________________________