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Virtual Counselor Referral Form
Please fill this out if you'd like to talk with one of us. We will do our best to get in touch with you within 24 hours of receiving this. <3 Mrs. Howard & Mrs. Bagley
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First and Last Name
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Your answer
Today's Date
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MM
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DD
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YYYY
Grade
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Choose
K
1
2
3
4
5
6
7
8
How are you doing?
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I'm great!
I'm ok
I'm struggling
I'm not good and I really need to talk
Other:
How are things outside of school?
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Horrible
1
2
3
4
5
Things are great!
Tell us a little bit about what you would like to talk about...
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Your answer
Please let us know how you would prefer to get in contact
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Email
Phone
Zoom
Email address or phone number (please list the best way to get in contact with you!) If you want to meet over Zoom, still leave us your email address so we can schedule a Zoom call with you.
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Your answer
I'd prefer to talk to...
Mrs. Howard
Mrs. Bagley
I don't have a preference!
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