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Ms. Edwards Counseling Referral Form
Quick form for seeing Ms. Edwards for counseling
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* Indicates required question
Name (First, last)
*
Your answer
Teacher? (Teacher you are currently with)
*
Option 1
Have you talked with your teacher about what's bothering you?
*
Yes
No
Reason for counseling referral
*
Family issues
Friend problems
Personal problems
Academic (school related issues)
Other issue
Required
This is...
*
Emergency (Right now/cannot wait)
Very important (later today, tomorrow)
Can Wait (anytime this week)
Submit
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