NIS Counselor Request Form
Thank you for making a referral. 
If an emergency exists, you are welcome to use this form but please also contact a counselor immediately through the front office.
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Email *
Date *
MM
/
DD
/
YYYY
Student Name (First and Last Name) *
ID # *
Grade *
Name of Person Making Referral
When does the counselor need to check in? *
Reason for Referral *
Required
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