School Counselor Case Management Intake Form
Student Information
Student Name
Student ID
Grade
Date of Birth
Parent/Guardian Name
Contact Information
Referral Information
Date of Referral
Referrer Name/Role
Reason for Referral
Presenting Issues
Summary of Issues/Concerns
Academic/Behavioral Information
Academic Performance
Behavioral Concerns
Interventions and Support
Previous Interventions/Support Provided
Support/Actions Requested
Other Notes
Additional Comments/Notes