Social Squad Referral Form
Social Squad
Counseling Referral Form
Confidential Referral
Standardized Social-Emotional Support
Student Name
Grade / Teacher
Referred By & Date
Duration of Concern
e.g., 2 weeks, since start of year
Primary Social Concerns (Check all that apply)
Difficulty joining peer groups
Unaware of personal space
Trouble sharing or turn-taking
Physical aggression with peers
Difficulty reading social cues
Using unkind words/name-calling
Prefers to play alone (exclusion)
Struggles with losing or rules
Requires constant adult mediation
Unfamiliar with classroom norms
Level of Urgency
Low Med High
1
2
3
4
5
Interventions Attempted
Strategy Used
Helped?
Brief Outcome
Y
N
Y
N
Family Communication
Is the family aware of these concerns?
Yes
No
Family Response / Notes
Additional Observations / Notes
Please include any specific triggers, strengths, or peer dynamics noted.
Navigating Friendships Together
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