Counselor Appointment Request Form

Last Name *

First Name *

E-mail Address *

Class Year *

Reason(s) for Visit: *

Academic/grades

Attendance

College credit

Family issues

Friendship/peer issues

Graduation

Mental health (sadness, depression, anxiety, grief, etc.)

PSEO

Schedule - this year

Schedule/registration - next year

Teacher concern/conflict

Other:

Required

Is there anything the counselor can prepare or complete before the meeting?

Cell Phone Number (you will get a text reminder about your appointment)

Ms. Zemple will schedule you for an appointment through your Google Calendar. *

OK!