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Counseling Request Form
School Counseling Request
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* Indicates required question
Email
*
Your email
Today's date is...
*
MM
/
DD
/
YYYY
I am a....
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Student
Parent
Staff Member
If a parent or staff member, please write your name and contact information
Your answer
Student's Name or School ID (if know, school ID only)
*
Your answer
Grade
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
I don't know
My homeroom teacher is...
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Choose
Mrs. Grayson (Kindergarten)
Mrs. Lake(Kindergarten)
Mr. Stevens (1st)
Ms. Munoz (1st)
Ms. Stucky (1st)
Ms. Flatt (2nd)
Ms. Maddagan (2nd)
Mrs. Ruiz (2nd)
Mrs. Tribbett (3rd)
Mrs. Pacheco (3rd)
Ms. Carroll(3rd)
Ms. Tedeschi (4th)
Mrs. Akers (4th)
Ms. Murillo (5th)
Mrs. Wies (5th)
Ms. Acedo(6th)
Ms. Brown (6th)
Mr. Garapan (7th)
Mr. Soberano (7th)
Mrs. Rangel (7th)
Mr. Pearson (8th)
Mrs. Howard (8th)
Mr. Neckels (8th)
I don't know
Pick One
*
I want to check in with you
I have a small problem
I have a BIG problem (if this is an emergency that requires action, please seek emergency response from one of the agencies at the bottom of the form)
My problem or concern is related to
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School
Home
Friends
Bullying/Cyber Bullying
Safety and/or Emergency
Other:
Required
My teacher or school staff is aware of my situation
*
Yes
No
I am a staff member
My parent or guardian is aware of my situation
Yes
No
I am the parent/guardian
Clear selection
Is this situation an emergency (safety and health)?
Yes
No
Clear selection
If yes, please contact a trusted adult AFTER you submit this referral.
If no, please allow 48 hours for Mr. Covert to respond.
Pendergast School District Resources
If you need immediate support or assistance, please check out these resources
Quick Tip (FREE)
www.pesd92.org
Teen Lifeline (Call 602-248-8336) (FREE)
https://teenlifeline.org/
Crisis Response Network (602-222-9444) ( FREE)
https://www.crisisnetwork.org/
If you have a medical emergency please dial 911, if not please contact the NON-EMERGENCY Number for CRIME STOP (602-262-6151)
https://www.phoenix.gov/police/contact-police/emailpolice
A copy of your responses will be emailed to the address you provided.
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