Ms. Martone's Counseling Request Form

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Ms. Martone's Counseling Request Form

Please fill this out to request a meeting with Ms. Martone.
VIRTUAL COUNSELING LIMITATIONS; I will keep my side of our conversations private, but I cannot make sure it stays private at your home. Please be aware that there may be other people listening to what you say at home.

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What is your name? *

What grade are you in? *

Kindergarten

1st grade

2nd grade

How are you feeling? *

I am in the Green Zone (ready to learn, happy, calm, focused, OK).

I am in the Yellow Zone (frustrated, worried, excited, silly).

I am in the Red Zone (refusing to work, out of control, mad/angry, hands on).

I am in the Blue Zone (sad, sick, tired, bored, moving slowly).

I would like to have a Google Meet with Ms. Martone. *

Yes, please contact my family.

No, I am doing OK.

Is there anything else you would like me to know about? *

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