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Counselor Referral Form by Teacher/Parent

Zamora Middle School Counselor Referral Form 2026-2027

Form must be COMPLETELY filled out by faculty/parent making the (*non-emergency) referral, prior to the counselor seeing the student(s).

Reasons for parents to contact the counselor:

  • Concerns about student academic achievement
  • Improving parent-child communication
  • Discussing student interventions
  • Assistance with managing a family crisis
  • Child experiencing depressive symptoms or abuse
  • Resources for food, shelter, basic needs


*An emergency is when there is imminent harm to that person or someone else. If this is the case, please contact 911 IMMEDIATELY; you DO NOT need to fill out this form.