Counseling Appointment Request

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Thank you for taking the time to fill out a request to set up a counseling appointment.

Hi! My name is Ms. Creighton and I am your school counselor.

I work at Magnolia and Arete.

I am at Arete on Wednesday 8:30-11:30 am and Thursday all day.

I am at Magnolia on Monday, Tuesday, and Friday all day. As well as, Wednesday from 12:00-3:30 pm.

What school do you attend? *

Magnolia Intermediate School

Arete Charter School

First and Last Name *

What grade are you in? *

I would like to talk about *

Social (conflict with friends or other students)

Emotions (dealing with my feelings)

Stress Management

Grades/Schoolwork

Attendance

Anxiety

College and Career Planning

Other:

Required

Coping Skills that I have tried and have found success with
*

Breathing Exercises

Exercising/Yoga/Dancing/Walking

Fidget Toys

Drawing/Painting

Building/Puzzles

Music: Listening/Playing

Talking to an adult

Talking to a trusted friend

Journaling/Writing how you feel

Saying kind affirmations (I am kind..)

Watching my favorite show/movie

Video Games

Other:

Required

I understand if it is an emergency, I will contact a trusted adult on campus, such as a teacher, aide, principal, or someone in the office. *

Yes, I understand.

No, I don't understand.

I understand that my counselor is on campus 3 full days per week and 1 half day per week at Magnolia.

I understand that my counselor is on campus 1 full day per week and 1 half day per week at Arete.

It may be a few days before she can get to me.

Yes, I understand.

No, I don't understand.

I understand if it is an emergency, I will contact a trusted adult on campus, such as a teacher, aide, principal, or someone in the office.
*

Yes, I understand.

No, I don't understand.

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