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BHS Counseling Request Form
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Time
Time
:
AM
PM
Student's First Name
*
Your answer
Student's Last Name
*
Your answer
Grade
*
9th
10th
11th
12th
Required
Who would you like to see?
Mrs. Hicks
Mrs. Shank
Either
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What is this concerning?
*
Emotions (angry, sad, lonely, etc.) ππ’
Friend issues π€·ββοΈπ€·ββοΈ
Family issues π
Academics π
Need someone to talk to ππ¬
Need school supplies/hygiene products/snacks/food/clothes ππ₯
Otherπ
Required
Send me a copy of my responses.
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