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Langford School Counselor Referral
Please complete this form if you would like assistance from a Langford School Counselor
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* Indicates required question
Name of student
*
Your answer
Your Name if different than above
*
Your answer
You are a ...
*
Langford Middle School Student
Langford Middle School Parent/Guardian
Langford Middle School Teacher/Staff
Other
Area of Concern
*
academic advisement
social/emotional (stress, anxiety, depression)
bullying
conflict w/ others
grief
behavior
Other:
Brief description of situation
Your answer
Best way to contact the student is by?
In-Person
phone call or text
email
Other:
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