Counselor Appointment Request Form

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Your school counselors would love to see you! Please fill out this form to set up an appointment. You can also look for us during our drop in hours before school, during lunch, and after school.

****IMPORTANT****
If you or someone you know is self-harming or, having thoughts of suicide please speak with ANY adult Immediately instead of filling out a counselor request form!

Email *

Do you understand the above statement? *

Yes

First Name *

Last Name *

Student ID # *

Grade *

6th

7th

8th

What would you like to meet about? *

Academic Concern (grades, difficulty in class, college & career questions, etc.)

Grief/Loss (death in family, etc.)

Family Concern (divorce, etc.)

Personal Concern (friends, bullying, etc.)

I have great news!

Required

Do you want help solving a conflict through peer mediators?

Yes

I am not having a conflict

Clear selection

Please provide a brief description of what you would like to discuss or solve. *

Would you like to be emailed answers to questions or appointments? * all emails will be sent to your school gmail account.

Yes, Email me

No, I do not prefer Email

Clear selection

A copy of your responses will be emailed to the address you provided.

Submit

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