Request to see a BCI Counselor

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Mrs. Jones - Last Names A-G

Mr. Seibert - Last Names H-O

Mrs. Hester - Last Names P-Z

As your counselors, we want to provide you with our best support, but we may not be able to review this form by the end of each school day. If you have a concern that you or another person is hurt, or could be hurt, please share your concerns with trusted adult immediately instead of completing this form.

Email *

My counselor is...

Mrs. Jones (last names A-G)

Mr. Seibert (last names H-O)

Mrs. Hester (last names P-Z)

Clear selection

Last Name *

First Name *

Student ID *

Grade *

5th

6th

I'd like to discuss... *

Academics (grades, schedule)

Personal (friends, family, emotions/feelings, challenges)

My future (college, career)

Give us a little more detail about what you need to discuss. *

How urgent is this matter? *

Not urgent, get to me when you can!

Pretty important. Please get to me within 24-48 hours

Urgent! If someone could get hurt, or it's a life threatening matter, please report to the closest adult immediately.

I understand that anything I talk about with the counselor is confidential UNLESS my safety or someone else's is at risk. If I report I will hurt myself or someone else, the counselor will need to tell someone else.
*

Yes, I understand.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Keller ISD. Report Abuse

Forms