Counseling Self-Referral

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Reqiest to see your School Counselor or Social Worker.

Before you fill this out, please think about these questions:
*Have I tried to solve the problem myself first?
*Can I walk away or let it go?
*Will this still be a problem tomorrow?

First Name and Last Name *

My KORT Teacher *

My Counselor/Social Worker is: *

Mrs. Wigfield--Students with the last name: A-L

Mrs. Mesna --Students with the last name: M-Z

Mrs. Buskey --Social Worker

Grade *

5th Grade

6th Grade

7th Grade

8th Grade

What would you like to talk about?

My Schedule

My Academics

College/Career advising

I am aware of a bullying issue

Interaction/Problem with teacher(s)

Interaction/Problem with student(s)

I am concerned about another student

I have a personal problem

Any additional information that would be helpful for us to know.

Please connect with me: *

At your convenience

As Soon as Possible (ASAP)

Communication Preference: *

Counseling Office

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