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Online Counseling Request Form
Please fill out all portions and make an online appointment. I will call or email to set up a time to meet. If it is urgent please call or text my cell at 530.812.3300.
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* Indicates required question
Student Full Name (first and last)
*
Your answer
Parent/Guardian Full Name
*
Your answer
Who is filling out this form?
*
Parent/Guardian
Student
Student and Parent/Guardian
Other:
School of Attendance
Your answer
Grade Level
*
Choose
K
1
2
3
4
5
6
7
8
9
10
11
12
Best Contact Phone Number and/or Email
*
Your answer
Meeting Preference
*
Video Chat via Zoom (I will email you the appointment link to the email provided above).
Phone Call (I will call the number provided above at the scheduled meeting time).
Briefly let me know what you want to meet about:
*
Your answer
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