Student Self Referral Counseling Form
"All children should be taught to unconditionally accept, approve, admire, appreciate, forgive, trust and ultimately, love their own person." ~ Asa Don Brown
Best time to contact me
I need to talk to you about:
Urgent!!! Something private right away!
Illness or loss of a family member or friend
A friend I am worried about
My angry feeling
Relationship(s) with friend(s)/ peer(s)
Relationship(s) with adult(s) e.g., parent(s)/ teacher(s)
Relationship(s) with sibling (s)
Someone is bullying me
I think I might be a bully myself
I want to feel better about myself
Saying "NO!" and "STOP IT" to friends who want me to do things I don't want to do
My grades and schoolwork
Planning now for the future(e.g. career choices, post-secondary options)
Something else, I will tell you when I see you!
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