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Scheduling Appointment
Please use this form to make an appointment for counseling. Notify me a day early if you are canceling your appointment. You can reach me through the WRUSD email:
lbegay@wrschool.net
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* Indicates required question
Email
*
Your email
Student Name (First Name, Last Name)
*
Your answer
Student Grade:
*
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Person completing and submitting this form:
*
Student
Parent
Guardian
Aunt
Uncle
Grandparent
Teacher
WRUSD Colleague
Other:
Parent/Guardian Names:
Your answer
Active Email Address and working Phone Number:
Your answer
Reason(s) for Referral:
*
depression
aggressive behavior - physical or verbal
anxious - worries/crying
withdrawn
defiant
grief
domestic-violence
divorce
other home situation
Choose one of the following:
*
Individual Counseling
Group Counseling
SAP - Student Assistance Program - Support Group
Appointment Date:
MM
/
DD
/
YYYY
Appointment Time:
Time
:
AM
PM
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