About this template
The School Counselling Referral Form is designed to help educators, administrators, and support staff systematically identify and refer students who may benefit from professional mental health or wellbeing support. By standardizing the referral process, schools can ensure that critical information is captured consistently, allowing counselling teams to prioritize cases and provide timely interventions.
This template covers essential student information, the specific reasons for the referral, relevant behavioral history, and current support status. It also includes sections for parent consent and privacy acknowledgments, ensuring that the referral process remains transparent and professional. Using Doc2Form to deploy this as a Google Form allows your school to centralize data, reduce paperwork, and maintain a secure digital trail of student support requests.
Key features
- Standardized fields for consistent student data collection.
- Built-in sections for consent and privacy disclosures.
- Easy tracking of referral status and follow-up needs.
- Mobile-friendly design for quick access by teachers.
- Securely stores data in your connected Google Drive.
Use cases
- Referring students for emotional or behavioral support.
- Documenting academic concerns that may require counselling.
- Tracking external agency involvement for student welfare.
- Managing parent-approved counselling intake requests.
What this form collects
- Student Full Name (Short answer)Enter the student's legal first and last name.
- Year Level (Dropdown)Select the student's current grade or year level.
- Referrer Details (Short answer)Provide your name and contact information for follow-up.
- Reason for Referral (Paragraph)Briefly describe the primary concern regarding the student's wellbeing or behavior.
- Relevant History (Paragraph)List any previous interventions or relevant background information.
- Parent/Guardian Consent (Multiple choice)Has the parent or guardian been informed of and consented to this referral?
- Supporting Documentation (Paragraph)Please paste a link to any relevant files (e.g., incident reports, work samples) stored in your secure school drive.
- Privacy and Confidentiality Agreement (Multiple choice)By submitting this form, I acknowledge that the information provided is accurate and will be handled according to school privacy policies.
FAQ
How can I ensure this form is secure?
Because this form uses Google Forms, you can manage access permissions directly through your Google Workspace, ensuring only authorized staff can view sensitive student data.
Can I add custom questions for my specific school district?
Yes. Once you convert this template to a Google Form, you can add, remove, or edit any questions to align with your school's specific reporting requirements.
How do I handle file attachments like incident reports?
Google Forms does not support direct file uploads in all configurations. We recommend using a text field for staff to paste a link to a secure Google Drive folder containing the documents.
Is this form suitable for emergency situations?
No. This form is intended for routine referrals. If a student is in immediate danger or crisis, please follow your school's established emergency protocols.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.