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Request for Counselor Assistance
Please complete this form for any student who needs academic, behavior, or social/emotional support.
Email address *
Student Name (Last name, First name): *
Your answer
Grade *
Name of person requesting assistance. *
Your answer
Relationship to Student: *
Please select all areas of concern: *
Student needs to see the counselor: *
Additional information that may be helpful: *
Your answer
Your contact information (phone# and/or email): *
Your answer
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