Request to Visit the Counselor

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Please only use this form for NON-emergencies. Only fill out the form 1 time regarding the same request/situation. Mrs. Edge or Mrs. Kennedy will visit with you as soon as possible. If this is an emergency, please get an adult immediately.

If the counselors are out of the office or in meetings, we will get to you as soon as possible.

First Name *

Last Name *

Grade *

Teacher

I would like to talk to you about... *

my school work

my friends

my family

a conflict

a possible bullying situation

something else

Tell me a few more details, if you can. *

Have you talked to anyone else about this? *

Yes

This... *

is an EMERGENCY! (someone is getting or may get hurt) - STOP AND GO TELL AN ADULT!

is important - no one is getting hurt, but I can't stop thinking about it

can wait - just something I'd like to talk about sometime

Enviar

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