Request for Assistance
The purpose of this form is for staff/parents/students to request the assistance of a  school counselor/social worker due to student concerns.  
**STUDENTS, DO NOT COMPLETE THIS FORM IF YOU OR SOMEONE ELSE IS  HURTING THEMSELVES OR SOMEONE IS HURTING YOU. PLEASE SEEK HELP FROM  A COUNSELOR/SOCIAL WORKER IMMEDIATELY.**
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Email *
Date  *
MM
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DD
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YYYY
Student's Grade Level *
Required
Student's Name *
Reason for Assistance *
Required
Please tell me your concern: *
Person filling out this form & contact info: *
Who are you in relation to the student? *
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