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Petaluma City Schools Counseling Self-Referral Form/Formulario de autorreferencia de consejería de las escuelas de la ciudad de Petaluma
School-based Mental Health Counseling / Consejería de salud mental en la escuela

Form submitted to Linda Walsh, LMFT, District Guidance Coordinator lwalsh@petk12.org 707-249-3526/
Formulario enviado a Linda Walsh, LMFT, Coordinadora de Orientación del Distrito lwalsh@petk12.org 
707-249-3526
Email *
Your Name/Tu Nombre
Date/Fecha
MM
/
DD
/
YYYY
School/Escuela *
Your Grade/Tu Grado
What is your cell phone number?/¿Cual es tu numero de celular?
What is your school email address?/¿Cual es tu correo electrónico escolar?
What’s the best way to contact you?/¿Cual es la mejor forma de contactarte?
Clear selection
Language Preference/Lenguaje Preferido
Clear selection
Which type of counseling is being requested?/¿Qué tipo de asesoramiento se solicita?
Clear selection
Please share the reason you are seeking support for yourself./Por favor comparte la razón por la cual estas buscando apoyo.
Please share any additional information you would like the counselor to know./Por favor comparte cualquier otra información adicional que quieras compartir con el consejero.
A copy of your responses will be emailed to .
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