Sunnyside Counselor Request Form For Students

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Thanks for reaching out. I am excited to connect with you! We will schedule an appointment with you as soon as we can based on your responses. You can also email Rebecca at rjohnson10@pps.net or Alison at algemperle@pps.net

Email *

Student name (Last, First)

Core Teacher

Grade

I'm feeling

sad, tired, lonely, bored, unmotivated

scared, nervous, worried/anxious, stressed

Excited, happy, proud, motivated

upset, angry, terrified, out of control, unsafe

I would like to meet with Alison or Rebecca because:

I have a problem or feelings that I need to talk about

I am worried about a friend or classmate

I just want to say hi, share something, or connect

Other:

Clear selection

If there is something specific you would like us to know, please tell us briefly what is going on:

I would prefer to meet:

In the morning (between 9-12)

In the afternoon (between 12-4)

Clear selection

I would like to meet/communicate via:

In person

Google meet

Phone

Please provide a phone number and/or email address where we can reach you. Students, please note: if you give us the phone number of a family member, we will contact them to schedule an appointment with you): *

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