Summer SEL Referral Form
Summer Acceleration Program 2026 TLC Behavior Referral Form
Please evaluate student needs through a supportive, social-emotional learning lens.
Required Routing Path:
1. Teacher 2. Office 3. Ms. Leslie
Student Name
Grade / Class
Date
Referring Teacher
Time & Location of Concern
1. Student Strengths (Check 1 or 2)
Highly Cooperative
Enthusiastic / Participates
Resilient / Tries Again
Empathetic / Kind to Peers
Creative Problem Solver
Responds Well to 1:1 Care
2. Primary SEL Needs (Check areas needing counselor support)
Self-Regulation
Struggles with impulsivity, tantrums, calming down, or transitions.
Peer Relationships
Frequent minor conflicts, difficulty sharing, or physical boundaries.
Social Awareness
Difficulty reading peer vocal or bodily cues, lack of empathy.
Decision-Making
Struggles with safety, school guidelines, or problem-solving.
Self-Confidence
Negative self-talk, shut-down, anxiety, or high task avoidance.
3. Observed Setting (Check all)
Academic Work
Transitions
Lunch / Recess
Group Work
4. Strategies Tried First (Check all)
1:1 Supportive Talk
Change of Seating
Quiet Calm-Down Break
Adjusted Assignment
5. Quick Description (Optional - 1 Sentence)
Counselor Action Log (Ms. Leslie)
To Be Completed By Counselor
Student pulled for 1:1 support
Restorative / peer coaching session
Coping plan or safety plan developed
Family Contact Made Date: _________________
Immediate Next Steps / Actions:
Ms. Leslie's Signature: _________________________________________
Action Date: _____________________
