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FREE Elementary School Counseling Student Self-Referral Form. In Spanish, too!



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This easy to use student self-referral form, in both English and Spanish, was designed to help students communicate that they’d like to see you, encouraging self-advocacy and agency. It asks students to designate what type and size of problem they are dealing with, using visuals and weather metaphors. This information can help you determine how soon you need to touch base with the student.

You can place these forms outside your office, alongside pencils to write with, and invite students to fill out their request to meet with you. Have students either slide their completed form under your door or place in a designated mailbox/dropbox. You can also distribute this form with teachers to pass out to students who express they’d like to see you.

I hope this student self-referral form is useful for your school counseling program.

Feedback is greatly appreciated. School Counseling On!

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