Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
2019-2020 Distance Counseling Check In
Sign in to Google
to save your progress.
Learn more
* Indicates required question
LAST Name
*
Your answer
FIRST Name
*
Your answer
Are you a........
*
Student
Parent / Guardian
Student and Parent / Guardian
Other:
Grade Level
*
6th
7th
8th
Other:
Contact email and phone number
*
Your answer
Primary Area of Concern is...
*
Academic
Social/Emotional
College/ Career
Friendships
Non-Emergency URGENT
Other:
Reason for Visit (check all that apply)
*
Personal Concern
Classroom Concern
Transition to Middle School
Transition to High School
Small Group Question or Concern
Other:
Required
How do you want to be contacted?
*
Email
Phone
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Uinta County School District #4.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
