Student Self-Referral Form

Many times throughout the school year, students will need and want to visit the school counselor to discuss their problems.  I mentioned a form I use in a previous post which uses “rocks” to help describe the urgency of the referral.

My original form included pictures which I couldn’t post for distribution because of the copyright, so I chose a picture of a rock from a free clip art site,, for the purposes of sharing the form here.  Click HERE to print the form.

Students can select one of the following options:

A Small Rock  (See me soon!)

A Medium Rock  (See me this week!)

A Large Rock  (Urgent!  See me as soon as possible!)

As I receive forms from students, I will write an appointment in my calendar and then write it on the form.  Once I see the student, I will check or initial that the appointment has occurred for documentation purposes.  I then store these forms by grade level in a plastic file organizer.

I also created a small 8.5 x 11 poster explaining and listing  some examples.  This helps so students don’t check “Large Rock” when they need to work on making friends or disagree with a teacher.  This can be printed with a border or you can back it with a nice patterned paper. Click the picture below to print.

Stick around!  You can follow Savvy School Counselor with free email updates.  As always, I’d love to hear from you.  Do you tend to have a large number of student self-referrals at your school?

5 thoughts on “Student Self-Referral Form

  1. Love it! I think I might actually do this with a balloon metaphor. It would go along really well with the intro lesson that I do where we add air to the balloon for each problem–a little air for “little” problems and a lot of air for “big” problems. We then discuss that when your balloon is very full then you might need to see your counselor.

  2. I love this idea, and have began to try and implement this with my students. My only issue is figuring out how to display it so that kids will have access to it at all times (I am split between two schools), and making it visible. Do you have any suggestions on ways to hang the signs up and to make the slips more available? Thank you in advance for you help, and for the wonderful ideas on this website!!

    • Hi, Jade! Thank you for your comment. I hang a pocket with forms and signs on my office door so students always have access to them. You can also give a few to your teachers.

  3. Thanks for the rock idea… It helped curb the task avoidance visits from students. Now that they have to take time and think/rate the level of the problem I have less in the way of minor issues and more in the way of serious matters to deal with. Thanks again!! Great site!:)

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