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Request a visit with Ms. Pence (School Counselor)
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* Indicates required question
Email
*
Your email
Student name
*
Your answer
Student Grade
*
Your answer
date
*
MM
/
DD
/
YYYY
Referral source (who is asking they be seen?)
*
Student/Self
Teacher
Parent
Other:
Required
Reason for seeing school counselor
*
Personal
Grades
Hard time in class
Other:
Required
Please click any reasons that apply to you or your student:
*
worrying about school or home
feeling sad
feeling angry
classroom difficulties (focusing, distracted)
Grades- struggling with content or getting work done
having a tough day
Just need someone to talk to
Happy and want to share something good that has happened
having a hard time with another student/friendship issue
missing someone
something not on the list
Other:
Required
If this situation was like the weather, how would you rate it?
*
kinda cloudy (see me by the end of the week)
rainy (please see me today at some point)
Thunderstorming (please see me as soon as possible)
Sunny (my day is going well and I just want to share something or pop in)
Other:
Required
Is there anything else you would like for me to know?
Your answer
who is one trusted person you can turn to in the meantime?
*
Your answer
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