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2020-2021 School Counselor Referral - Student
Hello from Ms. Pawlcyn!
This is such a new and different start to the school year. I am here for you as we work through this together at Horizon. Please use this form to reach out to me.

Thank you for being brave and knowing when and how to take care of you!

No one will see the information you submit, except for me, UNLESS the 3 cardinal rules come into play and you tell me that: Someone is hurting you, you want to hurt yourself or you want to hurt someone else.

Please fill out the questions, hit submit and I will get back to you as quickly as I can.

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First Name *
Last Name *
Your Teacher *
How are you right now? *
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How is school going?
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How are things at home?
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Tell me a little bit about why you are reaching out... *
What are 2 things you can do when you have BIG feelings (mad, sad, scared, nervous) *
How would you like me to reach you if you are learning from home. *
Who is completing this form? *
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