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Counseling Request Form
Complete this form to make an appointment to see your school counselor. If this is an emergency or crisis situation, contact 911 or call/text the National Suicide and Crisis Lifeline at 988.
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Date
MM
/
DD
/
YYYY
Your Email Address
Your answer
Student Last Name
Your answer
Student First Name
Your answer
Grade Level
9th
10th
11th
12th
Clear selection
Have you or the student you are referring ever met with a Counselor?
Yes, I have met with a counselor
No, I have never met with a counselor
I can't remember/don't know
Clear selection
Who is referring this student?
Choose
Myself
Another Student
Teacher/Staff
Admin
Parent/Guardian
What time frame would be best?
The student would like to see a Counselor/Intern within a week or so
The student would like to see a Counselor/Intern within a few days
The student is in crisis and needs to see someone by the end of the day (crisis= someone may be in danger i.e. self-harm, child abuse, etc.)
Clear selection
What topic would you like to talk to the Counselor about?
Academics
College / Career
Social / Emotional Concerns
Other:
Clear selection
Please explain your request so we can be fully prepared for our meeting. What should we know?
Your answer
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