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Counselor Meet Request Form-Student
Hi friend, if you are struggling with something and you are needing some more support, we are here for you. Before we meet, help us to better understand what you are experiencing by filling out this form. Only the counselors will be able to see your answers:)


I need to see the School Counselor/Social Worker because...
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Which elementary school do you attend?
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Montgomery ES
Mercersburg ES
Saint Thomas ES
Mountain View ES
Not sure
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add "Other"
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Name (first and last, please!)
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Date:
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Answer key
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Time:
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Answer key
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Grade
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Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
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add "Other"
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How are you feeling today?
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1- Not good at all.
2- Could be better.
3- I'm okay.
4- Pretty good.
5- I'm great!
Other…
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I need to talk to you about...
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School
Family
Friends
Other
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or
add "Other"
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This is a...
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Small Problem (Please talk with me some time this week)
Medium Problem (Please talk with me some time in the next 2-3 days)
BIG PROBLEM (Please talk with me as soon as you can, I really need your help with something today)
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add "Other"
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What Coping Skills have you tried before reaching out to the School Counselor? (Check all that apply)
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Balloon Breathing
Take a walk
Had a snack
Played a game
Write in my journal
Take a break
Used the 5-4-3-2-1 Grounding Strategy
Shape Breathing
Brain Break
Dancing/Listening to music
Talk to a friend
Talk to an adult
Watched a movie
Draw/Paint
Excercise
I have not tried any Coping Skills
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How is everything at home?
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Anything else you'd like to share?
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I need to see the School Counselor/Social Worker because...
Which elementary school do you attend?
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Name (first and last, please!)
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Date:
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Time:
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Grade
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How are you feeling today?
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I need to talk to you about...
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This is a...
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What Coping Skills have you tried before reaching out to the School Counselor? (Check all that apply)
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How is everything at home?
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Anything else you'd like to share?
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