Request to see the counselor- Non Urgent

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Please complete this form if you believe a student would benefit from speaking with Ms. Pratt, school counselor. Student will be seen as soon as possible. Please note that information that is discussed with student will be kept confidential.

Student's Name *

Grade Level *

Kindergarten

1st

2nd

Name of person completing form *

Briefly describe the concern/reason for referral *

Would you like Ms. Pratt to follow up with you after she has spoken with the student? *

Yes

It is not needed.

If not Clairemont employee, please provide contact information if follow-up was requested.

Please provide any additional information about student that you believe would be beneficial for Ms. Pratt to know. (optional)

Submit

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