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Counselor Request Form 2023-2024
For Students and Staff
* Indicates required question
Email
*
Record my email address with my response
I am a
*
Student
Staff Member
Parent or Guardian of a Student
Name of person completing this form
*
Your answer
Name of student needing to see the counselor
*
Your answer
Where is the student right now?
*
School
Home
Is this an emergency?
*
I want to hurt myself or someone else
Someone I know is being hurt, wants to hurt themselves or another person
This is not an emergency
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