Counseling Referral

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Counseling Referral

Please complete this form and one of the counselors will contact you as soon as possible.

If you are thinking about harming yourself, please stop completing this form and call 911/seek help immediately. You can also access the "Say Something" reporting app here: saysomething.net.

Your name: *

email address *

What grade are you in?

6th

7th

8th

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Have you spoken to your counselor before? *

Yes, Mrs. Buehler (last names A-G)

Yes, Mrs. Dimeo (last names H-P)

Yes, Ms, Cook (last names Q-Z)

Yes, Mrs. Lopez (school social worker, usually at WMS on Tuesdays)

Yes, I meet with Mr. Walker on Wednesdays

Yes, I spoke to a counselor but not sure which one

No, I have not spoken to one of the counselors

Other:

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