Parent/Teacher School Counselor Request Form

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Please fill out this form to request for your student to visit Miss Kelso, the SES School Counselor during school hours. If you would like to speak to me directly, do not hesitate to contact me at:

Phone: 419-826-8991 ext. 4218

Email: elizabeth.kelso@swantonschools.org

If this is an emergency situation that cannot wait until the next school day, please contact:

Suicide Hotline: 988

Swanton Area Police Non-Emergency Number: 419-826-4696

Or, call 911 for emergencies.

Notice of Confidentiality

The following information submitted to me on the form will be kept confidential unless:

The student is unsafe
The student is a threat to themselves or others
Someone else is harming your student
You give me permission to share with involved parties

Your Name *

Student Name *

What is the purpose of the visit?

This section is important for keeping data on student needs. This information will be kept confidential.

Academics

Family concerns

Friendship concerns

Student concerns (self-esteem, behaviors, emotions, ect.)

Other:

Required

Please explain a little more about the reason I am seeing your student: *

What is the priority of the situation? Please choose "other" if you are unsure or if you have a different idea in mind. *

ASAP (Please speak to my student as soon as possible)

Urgent (See my student within the next 1-2 days)

Important (See my student within the next week)

Check-in (Check in with my student informally)

Other:

Anything else you want to add? (Optional)

Submit

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