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Request to See a Counselor
Please fill out this form to request to see a counselor.
Counselors will try to call you in within 48 hours if available.
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Realtionship to Student
Student Name (First and Last Name)
Student ID# (lunch number)
Counselor You'd like to see:
Ms. Cook (8th Grade Counselor)
Mrs. Denny (7th Grade Counselor)
Ms. Gomez (MTSS Counselor)
What do you need to see your counselor about?
Feelings (anger, sadness, lonely, overwhelmed, anxious, etc)
Future Plans (high school, college and career)
Comments (Information you'd like your counselor to know about your request.)
If you are feeling unsafe or in a crisis situation, please call 911 or the National Suicide Prevention Lifeline at 1 (800) 273- TALK (8255). Visit our districts wellness web site for hotline and textlines information at
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Riverside Unified School District.