Student Request for School Counselor

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I'm here to help and/or listen to anything you would like to talk about, vent about, or if you just want to say hi :).
You can fill out this form or email me through my school email.
I would love to hear from you!!!

Your Name *

Is the reason you are contacting me an emergency?

Yes, it is an EMERGENCY!!!

This is very important, but not really an emergency.

I want to talk to you, but if you are busy with an emergency, I will be ok for now.

Clear selection

Which school do you go to? *

What grade are you in? *

How do you want me to contact you? *

Please give either your phone number or email address (or both). *

Reason(s) for referral (check all that apply) *

My school work

My family

My friends

Myself

My class

Something secret or private

Just want to chat and/or say hi

Other:

Required

If you said "Other," please just give me hint of what you would like to talk about.

Please Read this Message:

Pick One about my message above: *

I understand what you are saying and agree.

I don't really understand and would like to talk about it with you to help me understand.

Submit

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