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Student Self Referral Form
Students: Please utilize this form to express any concern regarding a personal, home, academic, or social need. Responses will be recorded and sent to the appropriate person needed to address your concern(s).
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Student Name
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Your answer
9th
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9
10
11
12
Homeroom Teacher
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Your answer
I have a SELF CARE issue and need support with one of the following:
Anxiety/ Stress Management
Life Changes
Self Esteem/Confidence Building
Mental Health Concern
I have a HOME issue and need support with one of the following:
Family Difficulties / Concerns
Grief/Loss of a family member, pet, or friend
I have an ACADEMIC issue and need support with one of the following:
Grades / Test Taking / Study Skills
Time Management/ Organization Skills
After high school plans
I have an issue SOCIALLY and need support with one of the following:
Bullying
Friends/Peer relationships and/or conflict resolution
Relationships with Adults (i.e. parents, teacher, etc)
Teacher (or staff member) and students conflict or concern
Briefly explain and elaborate on your concern(s) below so that we may be able to support you more effectively. Thank you.
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Your answer
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