Student Self Referral to School Counselor 2023-2024

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I would like to meet with a counselor.

Last Name *

First Name *

Grade Level *

6th Grade

7th Grade

8th Grade

Pick one: *

I want to check in with you.

I have a small problem I need to talk with you about

I have a BIG problem I need your help with

Area of Concern *

Something happened to me at school

Something happening to OTHERS at school

Something happened to me at home

Something happening to OTHERS at home

Question about my schedule

OTHER

Please share a brief description of reason for visit:

I have tried to solve the problem on my own. *

True

False

Is this still going to be a problem tomorrow? *

YES

On a scale of 1 to 5, rate the severity of this problem. *

Not very severe

Very severe

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