See Mrs. Sample SCREENER

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If you need to see Mrs. Sample for any reason but are not ready to stop by on your own, please fill out this form and she will call you down to the office. Please understand that she may be busy, so it could take some time. But if this cannot wait for your mental or emotional health, please go to the front office immediately and ask to see someone right away.

You are ALWAYS welcome to just stop by Mrs. Sample's office if you are ready to do so. Please remember that if you stop by her office, you may be asked to fill this out before your conversation.

This email is not monitored outside of school hours. Do NOT rely on immediate communication during holidays, weekends, or evening. If you need immediate help during those times, please call 911.

And remember that you are valuable, intelligent, and worthy to be your best self!

Email *

Record my email address with my response

Student Name *

Are you a walk in or do you need to be called out of class? *

Walk In

Please Call Me Out of Class

Reason for Visit *

Mental or Emotional Health

Academic Advising

College, Career, or Military Advising

Discipline

Other

Level of Urgency *

1 - Nothing urgent. I just have a grade question that is a little more complicated than an email.

2 - Feeling a little worried or sad today. Minor problem. No hurry calling me out.

3 - I really would like to talk to you today about something that is weighing on me.

4 - Please call me out of class within the next hour or two if you can. I really need to talk.

5 - I am really struggling and need to speak with someone as soon as possible. Please call me out the minute you have a chance.

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