School Counseling Referral Form 2022-23
Please fill out the form below to see your school counselor. 
NOTE: Counselor does not check this form or e-mails after hours or over the weekends. If this is an emergency, please find the nearest adult that can assist you, or you can access help using the following websites: or (click top right corner to live chat with a mental health professional)
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Student LAST Name *
Student FIRST Name *
Email Address *
What is your grade level? *
What is the reason for your request? *
1 point
Provide some details regarding the above. *
1 point
Date *
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