Counseling Referral Form

Please fill out this form if you have a concern regarding a student that you believe could be assisted by the services of the school counselor or other mental health providers.

All fields are required.

Email
Student Name
Student Grade
Name of Person Referring
Relationship to Student
Primary Concern for Referral
Additional Details
(Please give any additional details, contributing factors, other services the student is receiving, or important information regarding your concerns)
Student Availability
(If you are a teacher referring, please indicate the best times to see the student during class)
Time Sensitivity

The mission of the Cardinal Community School is to foster an enriching environment and channel the energies of students to achieve their fullest potential.

Cardinal School District does not discriminate on the basis of race, color, age (for employment), socioeconomic status (for programs), religion, disability, creed, national origin, marital status (for programs), sex, sexual orientation, or gender identity in its educational programs and employment practices. There is a grievance procedure for processing complaints of discrimination. If you have questions or grievance related to this policy, please contact the district’s equity coordinator, Cindy Green.

The Cardinal Community School District offers career and technical programs in the following service areas:
Agriculture, Food, and Natural Resources
Health Science
Human Services
Business, Finance, Marketing, and Management

Cindy Green - cindy.green@cardinalcomet.com
Middle School Principal/Director of Curriculum & Instruction, Equity Coordinator
4045 Ashland Rd.
Eldon, IA 52554
(641) 652-7531

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