What should a teacher referral form for a school counsellor include?

Student name, class, teacher and date; a tick list of what the teacher has noticed; one line describing what they saw or heard; and whether parents are aware. It should also tell teachers to skip the form and bring the student straight to the counsellor if there is a safety concern.

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Tool 1

Teacher referral form

Updated 2026-10-30 · By Meera Manikandan, Counselling Psychologist, Counseld

In shortA one-minute slip teachers fill in when they’re worried about a student: student, class, teacher and date; a tick list of what they’ve noticed (sad or withdrawn, anxious, behaviour change, drop in schoolwork, often absent, friendship or bullying); one line on what they saw or heard; and whether parents are aware. Safety concerns skip the form: the teacher takes the student to the counsellor right away.

From practice Teachers tick, write one line and drop it in your box. You follow up from there. Prints two slips per A4 page: cut in two and share.

Teacher referral formCounseld

⚠ Safety concern or urgent need? Don’t use this form. Take the student to the counsellor right away.

Student name

Class

Your name

Date

What have you noticed? Tick all that apply

Sad or withdrawnWorried or anxiousBehaviour changeDrop in schoolworkOften absentFriendship or bullyingOther

In one line, what did you see or hear?

Parents aware?YesNoNot sure

Teacher referral formCounseld

⚠ Safety concern or urgent need? Don’t use this form. Take the student to the counsellor right away.

Student name

Class

Your name

Date

What have you noticed? Tick all that apply

Sad or withdrawnWorried or anxiousBehaviour changeDrop in schoolworkOften absentFriendship or bullyingOther

In one line, what did you see or hear?

Parents aware?YesNoNot sure

Using it in your school

Introduce the form when you meet each teacher team, and explain what you can and can’t share back.
Keep a box or tray outside your room, and a stack of slips in the staffroom.
Follow up with the teacher within a few days, even if it’s only to say you’ve seen the student.
Store completed slips with your confidential records, not in the staffroom.

New to talking with teachers about referrals? See the conversation starters in the First-Year Starter Guide.

Counseld Documentation Toolkit · Not a substitute for supervision, school policy or legal advice.

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