2019 - 2020 Teacher Counselor Request Form

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If you have a student that you would like to be seen by the School Counselor, please complete this form so that we can have some background information on how we can assist you and the student that you are concerned about. Please keep in mind, that due to confidentiality issues, we may not be able to share with you all that was discussed with this student.

Your First and Last Name *

First and Last Name of the Student Being Referred *

I would like for you to speak with this student about the following: *

This student is failing one or more classes

This student has attendance issues

This student is having a conflict with another student

This student has some home issues that I am concerned about

Other

Please explain below or go into more detail concerning what you checked above: *

Have you contacted this student's parent/guardian about this issue? *

Yes

We will always do our best to meet with this student as soon as possible, but please indicate below how urgent this concern is. *

When you have time to see them

It's an emergency

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