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Counseling Request Form
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I am a:
Student
Parent / Guardian
Clear selection
What is your name? (If a PARENT, please write down the student's name to which you are referring)
Your answer
Grade of student:
8
9
10
11
12
Clear selection
Counseling Need:
Personal/Social
Academic (Grades, Scheduling)
Other:
Clear selection
Personal/Social Needs - Check ANY that apply:
Bullying
Conflict with Friends
Family Issues
Illness
Loss of friend or family
Dealing with Emotions (anger, sadness, fear, etc)
Just need someone who will listen
Anxiety
Other
How urgent is this issue?
Low (Please meet within the week)
Medium (Please meet within 48 hours)
High (Please meet within 24 hours)
Emergency (need to meet immediately)
Clear selection
Please use this space to provide any additional information:
Your answer
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