Counseling Request Form

(Y)elder Development Program

Counseling Request Form

Person filling out form: □ Advisor □ Student □ Staff □ Parent Date:

Student’s Name: __________________________________________ Advisor:

Note: Counseling services are confidential. It would only be in extreme circumstances where other adults would need to be notified. Those circumstances will be discussed at each counseling session. This form will be kept private. Please fill out as much information as possible.

I would like to receive counseling services because (I would like to have this student receive counseling services because):

Please check all that apply. I have been (The student has been):

□ feeling depressed/sad □ feeling scared □ feeling angry □ feeling overwhelmed

□ having problems w/ family □ having problems w/ (my) partner

□ having personal problems: _________________________________________________________________________

□ having problems at school: _________________________________________________________________________

□ other:

I would like to receive information regarding (I would like this student to receive information regarding):

□ Sexually Transmitted Diseases □ pregnancy □ anger management

□ drug/alcohol abuse □ domestic violence □ developing positive study habits

□ other:

- - - - - - - - - - - - -

(For Staff Use Only)

□ I have reviewed this counseling request form and I approve that this student receive counseling services.

Staff (Advisor) Signature ____________________________________

- - - - - - - - - - - - - -

(For Youth Advocate/Counselor Only)

Counseling Session Appointment Date & Time: ________________________________

Student Notified: □ Appointment Met: □ Follow-Up Meeting: __________________________________________

Youth Advocate/Counselor Initials: ________________________________