Lee County High School Counselor Request Form

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Please complete the form below to request assistance from your school counselor. Information from this form will be kept confidential. Your school counselor will set up a time to meet with you as soon as possible.

***If this is an emergency (i.e. concerning suicide or a threat to others/school) please call 911.***
National Suicide Prevention Lifeline - Dial 988

My name is: *

Please include your first and last name.

Is this an emergency? (i.e threat to yourself/others/crisis - If this is after school please contact 911) *

Yes

I don't know

I am a *

Student

Teacher

Administrator

Parent

Other

Are you concerned about yourself? Or someone else? Please list a name here. *

The student's grade is: *

9th

10th

11th

12th

I don't know

My concern is... *

Academic (grades, graduation, schedule, classes)

Personal problem (anxiety, anger, friendship, family, moving, sad)

Attendance

Other

Please tell us what you are concerned about: *

What is your phone number?

What is your SCHOOL email address?

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