Student Self-Referral Form

Posted on

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?

A Bandage For Your Heart

Posted on

Hello all!  After a busy last week of summer vacation, I finally started back to work on Friday, August 17.  I was so excited to move BACK into my guidance office from the much smaller office I used last year.  While cleaning out one of the drawers in my file cabinet, I came across another lesson I’ve used for discussing when students should see the school counselor.   I want to share it with you today.

The activity is called A Bandage for Your Heart.  To make the bandages, I used manila paper.  I cut them 18 inches by 6 inches.  I used a brown crayon to draw the “look” of the bandage.  I cut small red hearts using construction paper.  On the opposite side of each bandage, I added some sentences giving some reasons students may want to complete a self-referral form to see me.

There are eight bandages which have the following sentences:

  • My grandmother died this summer, and I really miss her.
  • My daddy is sick all the time, and he never plays with me anymore.
  • There’s somebody who showed me a knife at school and told me I better not tell.
  • My mommy and daddy scare me when they fuss.
  • There’s somebody on the bus who keeps picking on me and hitting me.
  • I don’t have anybody to play with.  Nobody will be my friend.
  • I got a trophy at my soccer match last Saturday.
  • It’s my birthday, and I’m so happy!

Use the last two statements to give examples of non-urgent situations that do not require an appointment with the school counselor.  Explain that you definitely want to hear good news from them, but an individual counseling session just for that purpose isn’t necessary.

Also, you’ll want to wear a bandage on your shirt close to your heart.  If no one asks why it’s there, ask the students if they noticed anything when you came in the room. From there, begin to share and explain each of the bandages.  Many times,  I would talk about different sized rocks to help explain urgent vs. non-urgent referrals.  A big rock is urgent, and students might need to see you on the same day.  A medium rock means it’s important, but the counselor can see you sometime that week.  A small rock is something you want to talk about, but you can wait until the following week to see the counselor if necessary.  If you use this to assist with your discussion, have the students share examples of what they think a small, medium, or large rock would be.  This is also a great time to show students what the form looks like, where to find it, how to complete it, and where to return it.

Check out this Self-Referral Activity in my TpT store if you’d like to use this activity with your students.

Healing the Heart- Self-Referral Activity

Stick around!  You can follow Savvy School Counselor with free email updates.  As always,  I’d love to hear from you.  How do you explain self-referrals to your students?