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Counselor Request Form 2020-2021
Use this form when you would like to meet with Mrs. Goodrich. Thank you!
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* Indicates required question
Student Name (First/Last):
*
Your answer
Grade
*
Kindergarten
1st
2nd
3rd
4th
5th
Teacher:
*
Your answer
Reason for reaching out to Mrs. Goodrich:
*
Friends
Something at home
My parent or teacher said I should speak with you
Goal-setting
Help with solving a problem
Worries or something on my mind
Other:
Select the word that best describes your reason for needing to see the counselor.
*
Little problem (I need to speak with Mrs. Goodrich this week)
Medium problem (I need to speak with Mrs. Goodrich tomorrow or the next day)
BIG problem (I need to speak with Mrs. Goodrich as soon as possible)
What is the best way for Mrs. Goodrich to contact you?
*
In-person
Google Meet
Phone call
E-mail
Other:
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