JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Counselor Request Form
Fill out this form if you would like to meet with the counselor
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name:
*
Your answer
Grade Level:
*
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Freshman
Sophomore
Junior
Senior
Other:
Reason for visit (Why do you need to see the counselor?)
*
Your answer
Urgency (How severe)
*
Not Severe (Schedule changes, grades, scholarships, etc.)
Kind of Severe (Friend issues, problems, want to talk, etc.)
Severe (Bullying, very upset emotions/feelings, serious situations,etc.)
Very Severe (Harm to self or others)
What class period works best for you to meet?
*
Your answer
What teacher do you have that hour?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Nodaway-Holt R-VIII.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report