Counseling Referral
Please use this form to request counseling. Thank you!
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Who is making the referral? *
If Student: Please enter your name
If Staff: Please enter your name and the name of the referred student.
Grade Level *
Please give a brief description of the problem. *
If you are reporting abuse, neglect, suspected self- harm or thoughts of suicide, please contact the counselor or administrator directly if during school hours. If outside of school hours and an emergency, please dial 911 or The National Suicide Hotline at 800-273-8255. *
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