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Request to see Mrs. Miller, School Counselor
Please complete this brief referral form to schedule a meeting!
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Email
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Record my email address with my response
Name
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Your answer
Homeroom Teacher
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Grade
Kindergarten
1st
2nd
3rd
4th
5th
6th
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What are you looking for help with?
School/Classes
Friends/Classmates
Family/Home
My feelings/Myself
Top Secret!
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There is a....
Small problem, it can wait until you're available.
Medium problem, please see me soon within the next 3 days.
Big problem, please see me AS SOON AS POSSIBLE!
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I believe ________ will help me get back on track.
A meeting one-on-one with me
Briefly checking in with me
Catching up with you during lunch
Helping me and a peer work through an issue together
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Please share more information with me...
Your answer
Send me a copy of my responses.
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