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2019-2020 LEAD Counselor Parent/Guardian Referral Form
Parents/Guardians,

It takes a village, thanks for reaching out!

Please fill out this form if you would like the counselor to meet with your LEAD student and/or you are requesting a phone call or meeting with your student's counselor. We appreciate your support in helping LEAD students reach their full potential!

Have a great day!
~Mrs. Shanks, Counselor (Last Names A-K)
~Ms. Porter, Counselor (Last Names L-Z)
Email address *
Student Name *
(Last, First)
Your answer
Grade *
Student's LEAD Counselor *
Date *
MM
/
DD
/
YYYY
Referring Parent/Guardian Name *
Your answer
Academic Reason for Referral
(Check all that apply)
Social/Emotional Reason for Referral
(Check all that apply)
Do you consider this an emergency? *
I would like my student's counselor to contact me. *
The best time of day to contact me is:
A copy of your responses will be emailed to the address you provided.
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