Meet with a Counselor

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

The purpose of this form is to let the School Counselors know if you would like to speak to them about a mental health concern. Please fill out this information and we will get back to you as soon as possible to set a date and time to meet with you.

6th Grade School Counselor: Mrs. Velazquez
7th Grade School Counselor: Mrs. Padron
8th Grade School Counselor: Ms. Betancourt
ESOL School Counselor: Ms. Sanchez
School Behavioral Health Professional: Mr. Holmes

**If you or any other person is in a crisis or may be in danger, DO NOT USE THIS FORM. Please call 9-1-1 immediately.

Today's Date *

YYYY

First Name *

Last Name *

Relation to Student *

Self

Friend

Parent

Grade Level

6th

7th

8th

Clear selection

What mental health concern would you like to speak to a counselor about?
*

Parent/Guardian Name:
*

Parent/Guardian Phone Number:
*

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of School District of Palm Beach County. Report Abuse

Forms