Self-Referral Forms For School Social Workers And School Counselors
- File type
- Preparation
- Print ready
- Subject
- Social Emotional Learning (SEL), Special Resources
- Topic
- Referral Forms, School Counselors
- Preparation
- Print ready
From the author
About this resource
Give students a written way to request a conversation with the school counselor or social worker. This six-page PDF includes a cover, instructor note, two pages of self-referral slips and two pages of matching hall passes.
Each referral slip asks for the date, student name, teacher, conversation topic and size of the concern. Print copies for classrooms and explain how students should submit them. The instructor note suggests using passes with students who find it difficult to say when they need a break.
Referral topics can inform follow-up conversations and planning for a classroom curriculum. These are request forms and passes; appointment times and staff follow-up are arranged through the school’s own routine.
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In the classroom
Teaching tips & learning objectives
Teaching tips
Give teachers stacks of the referral slips to keep on hand in their own classrooms through the year
Reserve the hall passes for students who tend to keep concerns to themselves or find it hard to say out loud that they need to talk
Photocopy each page before cutting it apart, since a single page holds two identical referral slips or six identical hall passes
Skills covered
Self-advocacy — a student identifies a topic (family, friends, school, other kids, their own actions, or feelings) and rates how big the problem feels before requesting help.
Help-seeking initiation — a hall pass lets a student signal they need a private conversation without asking out loud in front of classmates.
Good to know
Questions teachers ask about this resource
What does a student fill in before handing in a chat slip?
Their name, the date, and their teacher, plus one topic checkbox (family, friends, school, other kids, their own actions, or feelings) and a rating for the size of the problem.
Do the two hall-pass designs ask for different information?
No — both use the same layout; only the heading changes, between I Need To See The Social Worker and I Need To See The Counselor, so the wording can match whichever staff member a student is sent to see.
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Resource details
Concepts & topics
Core concepts
Core concepts
Self-referral
Hall pass
Social-emotional check-in
Topics
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