Counseling Appointment Request

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Students: Fill out this form to be seen by a school counselor.

Name *

Grade *

6th

7th

8th

Which counselor would you like to see? *

Mrs. Bobo

Mrs. Lee

It doesn't matter: I just need to talk to someone.

I need an appointment for: *

Emotional issues (feelings of sadness, anger, etc.)

Social issues (drama, problems with friends, etc.)

Academic issues (I'm having trouble in my classes)

Other:

On a scale from 1-10 with 1 being the lowest (not a big deal, just see me when you can) and 10 being urgent *NOT an emergency, but urgent (I need to see you ASAP). Please rate your issue.**As a reminder, if you are experiencing thoughts of self harm, if someone is hurting you, you want to hurt someone else, or you are in an emergency situation and are not safe, please exit this form and tell a nearby trusted adult.** *

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