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Delker Appointment Request Form
Please complete this form to request a counseling appointment with me and I will get back to you ASAP. Thank you!
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* Indicates required question
Please write your name:
*
Your answer
Please write your email and/or phone number so that I can contact you:
*
Your answer
Student grade level:
*
Choose
9th grade
10th grade
11th grade
12th grade
What type of appointment are you seeking?
*
Check-in
Individual counseling
Group counseling
What do you need assistance with? (check all that apply)
*
Grades
Schedule change
Transcript
Scholarship assistance
Overall school performance
Goal setting
Career/college questions
Family dynamics
Relationships with peers and/or adults
Anxiety
Depression
Grief support
Positive self-talk
Calming strategies
Other:
Required
(Optional) If you would like to describe the area(s) you marked above, please do so below:
Your answer
(Optional) Is there anything else that I can do to support you at this time?
Your answer
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