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Student Self Referral
Students should complete this form when they need to see the school counselor
Name (Last, First Name)
Best period to pull me out of class
I need to see you about....
Check all that Apply
Dual Credit (College Courses)
Grief - Loss/Death
Having Trouble with an adult
Having Trouble with another student
Worried about my grades
Worried about home/family
Anything else I need to know before I see you?
I need to see you
Right away (It's an emergency!)
Sometime this week
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