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Request for Counseling Services
Please complete this form to request services from the school counselor for a student.
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Your Name:
Your answer
I am a....
*
Parent
Teacher
Staff Member
Student
Other:
Student's Name
*
Your answer
Homeroom Teacher
*
Your answer
Level of Urgency
*
Low (respond within 1 week)
Medium (respond within 2 days)
High (respond same day)
Please state the reason for your request.
*
Your answer
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