LS Student Referral Form

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LS Student Referral Form

Please fill out this form to see Mrs. Knipfer if you need help with a problem.

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NAME:

Your answer

I need to talk with you. I am feeling....

Sad

Angry

Worried/Stressed

Clear selection

I would like to talk to you about...

My school work

My family

Myself

My friends

My class

Other:

Clear selection

This

is an emergency.

is very important.

can wait.

Clear selection

Submit

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