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Counseling Request
Please use this form to make a request to see the school counselor.
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* Indicates required question
Who is making the request?
*
Self
Teacher
Parent
Other
Name of student being referred?
*
Your answer
Name of person making the referral: (Optional)
Your answer
Counseling Need
*
Personal/ Social
Academic
Personal/Social Needs. Check all that apply.
*
Skip if you chose academic need.
Bullying
Conflict with Friends
Family Issues
Emotions (Anger, fear, sad)
Anxiety/ Stress
Needing someone to talk to.
Grief (dealing with loss)
Other:
Required
How urgent is this issue?
*
Low (Please meet me within the week)
Medium (Please meet me within 48 hours)
High (Please meet me within 24 hours)
Emergency (I need to meet immediately)
Additional Information. Use this space to provide any further information or to request to set up a meeting.
Use this space to provide any further information or to setup a meeting.
Your answer
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