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Self-Referral Forms For School Social Workers And School Counselors

Four self-referral chat slips and twelve hall passes let students request time with a school counselor or social worker without needing to explain the reason out loud. Two slip designs, Counselor Chat and Speak With the Social Worker, ask a student to write their name, date, and teacher, check one topic among family, friends, school, other kids, their own actions, or feelings, and rate the size of their problem. A page of six hall passes reads I Need To See The Social Worker, and a matching page reads I Need To See The Counselor, so the wording can match whichever staff member a student is sent to see.
Year groups
Not year specific
File type
PDF
Preparation
Print ready

Instant download · Updated May 18, 2023

Subject
Social Emotional Learning (SEL), Special Resources
Topic
Referral Forms, School Counselors
Preparation
Print ready

From the author

About this resource

This Self-Referral Counseling Slips are the best resource to have as a school counselor! This resource allows students to reserve a time to speak with you when they feel as though they need it.

These referral counseling slips is a great back to school counseling resource that can be easily implemented. Simply print a bulk of forms and pass them out to teachers at the beginning of the year. They can placed in classrooms so when students feel as though they want to meet with the counselor, they easily can!

Benefits of Self Referral Counseling Slips:

  • Allows you to track all kids that you see

  • Helps with case notes at the end of the day

  • Helps to establish a baseline of needs that students might have

  • Can be used to implement push-in curriculum as a tier 1 support (if you see a lot of friendship related referrals, you know that this might be a need).

  • Helps to better manage your schedule while still maintaining flexibility

  • Helps to identify students who might need individual extra SEL support

When utilizing this activity, students will be able to advocate for themselves when they feel as though something is wrong, begin to identify when they need outside support, and form relationships with trusted adults!

Ideas For Use in Implementation:

⭐ Back To School Resource Packets

⭐ Open Houses

⭐ Meet the Teacher Nights

⭐ Push-In Lessons for tier 1 support

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

  • Self-referral

  • Hall pass

  • Social-emotional check-in

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