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Counseling Request
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* Indicates required question
Email
*
Your email
Middle School or High School
*
Middle School
High School
Today's Date
*
MM
/
DD
/
YYYY
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Who is initiating this request?
*
Teacher
Student
Parent
Other:
Reason for request:
*
De-escalation/ Cool Down
Conflict Resolution ( issue between 2 or more students)
Counseling for feelings, home-life, school, or friends
Academic
Other:
Priority:
*
Choose
High- student needs to talk to the counselor right away
Normal- student needs to talk to the counselor sometime today
Low- counselor can reach out to student when she can
What hours are best for you to be pull from? (Check all that apply)
*
1st
2nd
3rd
4th
5th
6th
7th
8th
Required
Please provide as many details of the issue/behavior/need as possible.
*
Your answer
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