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Student Self-Referral to Ms. Butler
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* Indicates required question
Your first name and last initial
*
Your answer
Today's date
*
MM
/
DD
/
YYYY
The name of the teacher I have right now is...
Your answer
I am having concerns about...
*
Friends
Family
Myself
Bullying
Grades
Other:
Required
How big of a concern is this for you?
Small, but important enough to talk to you.
1
2
3
4
5
Urgent--someone is going to be hurt today. (Tell an Adult immediately)
Clear selection
Before I filled this out, I tried...
Check all that might apply.
Working it out on my own.
Talking with a friend.
Talking with an adult at home.
Talking with a principal or teacher.
Other:
Is there anything else you want me to know?
Your answer
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