Request edit access
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:

Dial 9-1-1.
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. Learn more
What is your name? *
Who is your teacher, and what grade are you in? *
I need to talk about:
Clear selection
How soon do you need to see me? (I will do my best to see you when I am available)
Clear selection
What have you done to try to solve the problem?
Clear selection
Captionless Image
Clear form
Never submit passwords through Google Forms.
This form was created inside of Monongalia County Schools. Report Abuse