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Student Self Referral- Counselor, I need help...
I need help, I am… Please check the items below that are causing the most difficulty
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Student Name
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Your answer
Homeroom- Teacher name
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Your answer
Grade level
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Your answer
Please check the items below that are causing the most difficulty
Column 1
Worried about school
Worried about home
Worried about my grades
Having trouble with another kid
Having trouble with an adult
Trying to do it better, but it is hard
Confused
Sad
Missing someone
Can’t concentrate
Having a problem that is not on this list
Column 1
Worried about school
Worried about home
Worried about my grades
Having trouble with another kid
Having trouble with an adult
Trying to do it better, but it is hard
Confused
Sad
Missing someone
Can’t concentrate
Having a problem that is not on this list
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