At HOME Counselor Referral Form

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At HOME Counselor Referral Form - STUDENTS

This form is available for students to request to speak with the School Counselor.

Mrs. Ryals will be getting notified when you complete the form and will reach out as soon as she can. Please be sure to complete the entire form so she knows how to reach out to you. Be sure you tell your parents you are sending this to so they know you are communicating with Mrs. Ryals.

Email *

Today's Date *

YYYY

Name *

Teacher

I would like to see the counselor about:

my school work

my family

my friends

myself

my class

something private

Other:

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Any more information you would like to add:

This is: *

an emergency

is very important

can wait

The best way to reach me is... *

Phone

Skype

Facetime

Other:

Leave me the email or phone number to reach you at here: *

YOU ARE GOOD TO GO! I'LL BE IN TOUCH SOON! HUGS!!!

This form will be sent directly to Mrs. Ryals

Mrs. Ryals is working from home, just like you!

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