Student's Request Form

Student's First Name *

Student's Last Name *

Student's Grade Level

Parent's Name and Phone Number *

REASON FOR MEETING

( Select all that apply )

Academics

Emotional Health

Feeling Exploration

College Prep

Post Academics

Other:

Assigned School Counselor

S McCall M.Ed., LPC Students (A - J)

L Brown, M.A., PLPC Students (K - Z)

DISCLAIMER*

Counselors will meet with students, however, there is a duty to warn in case of students harming themselves, others or if someone is harming them.