Counselor Request

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Counselor Request

Please complete the form below if you need to speak to Mrs. Heller or Ms. Easter.

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Student First and Last Name: *

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Grade

K

1

2

3

4

5

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I need to talk to you about...

Friends

Family

School

Other:

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This is a...

Small Problem (I need to see you sometime this week)

Medium Problem (I need to see you in the next two to three days)

EMERGENCY (Safety Concern -- I need to see you AS SOON AS POSSIBLE)

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