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Midway Elementary: Student Self Referral Form for School Counseling Services
If you would like to see the school counselor, please fill out this form!
Thank you!
Mrs. Atkins
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* Indicates required question
First and Last Name:
*
Your answer
Grade Level
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Teacher:
*
Your answer
My problem is... (check as many as you need)
*
School🚌📚
Family / Home 🏠
Friends👫👭👫
Feeling Sad😔
Feeling Confused🤔
Feeling Scared😣
Feeling Angry 😡
Feeling Nervous 😬
Something Personal 💌
Other:
Required
This is:
a small problem
a medium problem
a BIG problem
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