Counseling Request Form

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Counseling Request Form

Thank you for contacting Mr. Clark and Ms. Mankins! We will contact you within 48 hours of our receiving this form unless you indicate it is URGENT!

Dustin Clark (A-K)
Katie Mankins (L-Z)

For an EMERGENCY contact Safe School Helpline: 1-800-4-1-VOICE (800-418-6423) or call 911.

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* Indicates required question

Email *

Your email

MM

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DD

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YYYY

Student Name, last-first *

Your answer

Grade *

Choose

7th Grade

8th Grade

9th Grade

Name of person making this referral *

Your answer

Please leave a brief reason why you, or who you're referring, needs to see the counselor. No one but the counselors will see this form. *

Your answer

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