Counselor Request Form

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Please complete this form to request a meeting or give information to the counselors. Students, parents/guardians, and staff members can complete this form and a counselor will address the request as soon as possible.

Email *

What grade level is the concern in?

6th

7th

8th

Clear selection

Please click a choice below *

I am a student

I am a parent/guardian

I am a PRMS staff member

Student First Name *

Student Last Name *

What kind of issue/concern do you have? *

Check all that apply.

I need time in the relaxation room today

I have a safety concern I would like to report

I need to talk to my counselor

I am a parent/guardian and would like you to contact me

I am a staff member and would like you to meet with a student

Other:

Required

Would you consider the issue/concern an emergency? *

Yes

I don't know

Please give a BRIEF description of your issue/concern. *

Submit

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