Counselor Request Form

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Counselor Request Form

Please fill out this request form if you are needing to meet with the Counselor.

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* Indicates required question

Name *

Your answer

I would like to see the Counselor because *

I have a problem a home or with family

I have a problem at school

I need to talk about something else

Other

Is this matter urgent? (**Urgent means you are worried about the safety of yourself or others) *

Yes

No

I am not sure

Is there anything you would like the Counselor to know before we meet?

Your answer

Submit

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