Walk In Counselor Check In
Students are required to fill this out when requesting to see a counselor for walk in or when they need a break in the counseling office.
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Date  *
MM
/
DD
/
YYYY
Time *
Time
:
Class Period *
Name *
Counselor *
Required
Do you see a School Based Mental Health counselor such as Frank, Rachel or Kayla? *
Who is your outside therapist or counselor?
Class/Teacher You left *
Why am I currently not in class? *
How am I feeling? *

What do I need to be successful while I am in class?

 *

How long do I need a break before I can go back?

 *

What positive choices will I make while taking a break?

 *

How do I plan to make up the time I missed?

 *

Going forward, what other options do I have besides leaving class?

 *

How is this behavior negatively affecting me at school?

 *

What can I do differently next time?

 *

How does this help me in the future?

 *
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