Student Self-Referral to Ms. Butler
Your first name and last initial
The name of the teacher I have right now is...
I am having concerns about...
How big of a concern is this for you?
Small, but important enough to talk to you.
Urgent--someone is going to be hurt today.
Before I filled this out, I tried...
Check all that might apply.
Working it out on my own.
Talking with a friend.
Talking with an adult at home.
Talking with a principal or teacher.
Is there anything else you want me to know?
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