Digital Counseling Referral Form Project Guide

Project Goal

To design and create a digital counseling referral form for students in grades 6-8, accessible to students, parents, and teachers, facilitating early identification and support for student needs.

Target Audience

• For Referral: Students, Parents, and Teachers of students in grades 6-8.
• Form Users: School counselors and support staff.

Key Components of Your Digital Referral Form

1. Referrer Information

• Purpose: To identify who is submitting the referral and their relationship to the student.
• Questions:
  • Referral Type: (Dropdown: Student, Teacher, Parent/Guardian, Other - please specify)
  • Your Name: (Text Input)
  • Your Relationship to Student: (Text Input - if Teacher/Parent/Guardian)
  • Your Contact Information: (Email/Phone - if Teacher/Parent/Guardian)

2. Student Information

• Purpose: To identify the student needing support.
• Questions:
  • Student's Full Name: (Text Input)
  • Student's Grade Level: (Dropdown: 6, 7, 8)
  • Student's ID Number (Optional): (Text Input)

3. Reason for Referral

• Purpose: To gather specific details about the student's needs and the observed concerns.
• Questions:
  • What are the primary concerns or observations regarding the student? (Long Answer Text)
  • When did you first notice these concerns? (Date Picker / Text Input)
  • How frequently do these concerns occur? (Dropdown: Daily, Weekly, Monthly, Rarely, Other - please specify)
  • What impact are these concerns having on the student's:
    • Academics? (Long Answer Text)
    • Social interactions? (Long Answer Text)
    • Emotional well-being? (Long Answer Text)
    • Behavior in class or at home? (Long Answer Text)
  • Have any strategies or interventions been tried already? If so, please describe them and their outcomes. (Long Answer Text)
  • Is there anything else you think the counseling team should know? (Long Answer Text)

4. Desired Outcome/Support

• Purpose: To understand the referrer's expectations for support.
• Questions:
  • What kind of support are you hoping the student will receive? (Checkbox: Individual Counseling, Group Counseling, Academic Support, Family Support, Crisis Intervention, Other - please specify)
  • What do you hope will change for the student as a result of this referral? (Long Answer Text)

5. Consent & Communication

• Purpose: To ensure appropriate communication and obtain necessary permissions.
• Questions:
  • Have you discussed this referral with the student (if age-appropriate and applicable)? (Yes/No)
  • Have you discussed this referral with the student's parent/guardian (if applicable)? (Yes/No)
  • Preferred method of contact for follow-up: (Dropdown: Email, Phone)
  • By submitting this form, I understand that the information will be shared with the school counseling team to provide appropriate support for the student. (Checkbox: I Agree)