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Counselor Request Form
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* Indicates required question
Name:
*
Your answer
Grade Level:
*
3rd grade
4th grade
5th grade
Today's Date
*
MM
/
DD
/
YYYY
How urgent is this?
*
EMERGENGY- We need to talk NOW!
Urgent- We need to talk sometime today.
Whenever- No rush, but sometime this week.
Right now, I feel
*
Angry
Stressed
Anxious
Frustrated
Depressed
Sad
Lonely
Other
Required
Do you want to hurt yourself or others?
*
No
Yes
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