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Student Self Referral Counseling Form
"All children should be taught to unconditionally accept, approve, admire, appreciate, forgive, trust and ultimately, love their own person." ~ Asa Don Brown
* Indicates required question
Name
*
Your answer
Contact number
*
Your answer
Email address
*
Your answer
Best time to contact me
Your answer
Class
*
Choose
1A
1B
1C
2A
2B
3A
3B
3C
4A
4B
4C
5A
5B
5C
IB 1
IB 2
I need to talk to you about:
*
Choose
Urgent!!! Something private right away!
Illness or loss of a family member or friend
A friend I am worried about
My angry feeling
Relationship(s) with friend(s)/ peer(s)
Relationship(s) with adult(s) e.g., parent(s)/ teacher(s)
Relationship(s) with sibling (s)
Substance abuse
Someone is bullying me
I think I might be a bully myself
I want to feel better about myself
Saying "NO!" and "STOP IT" to friends who want me to do things I don't want to do
My grades and schoolwork
Planning now for the future(e.g. career choices, post-secondary options)
Something else, I will tell you when I see you!
Submit
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