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Ms. Simunic's Student Referral Form
Fill out this form, and I will try to meet with you as soon as I can.
This form is NOT to be filled out in the event of an emergency. If you are in need of immediate assistance, or are in a crisis situation, please do one of the following:
Call or text a 24-Hour Crisis Hotline.
National Suicide Prevention Lifeline:
or call 1-800-273-8255 or
Crisis Text Line:
or Text CONNECT to 741741
Report to the closest Emergency Room.
Confidentiality Note: Confidentiality is a vital part of counseling. I strive to maintain your trust, safety and well being but are bound to ethical standards and must report any information that relates to threat of harm, harm to self, or suspected abuse of any kind.
The information is kept confidential and can only be accessed by the school counselor. Thank you!
Sign in to Google
to save your progress.
What is your name?
Who is your teacher, and what grade are you in?
I need to talk about:
Conflict with another classmate
How soon do you need to see me? (I will do my best to see you when I am available)
Sometime this week.
Sometime today if possible.
I need to talk as soon as possible.
What have you done to try to solve the problem?
Talk to an adult I trust
Positive Self- Talk
Ignoring others involved
Tried to talk to others involved
None of these
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This form was created inside of Monongalia County Schools.