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Request to See My School Counselor
Please fill in the following information to be seen by your school counselor. If it's an emergency, please go directly to the office.
* Indicates required question
Email
*
Record my email address with my response
First Name
*
Your answer
Last Name
*
Your answer
Student ID #
*
Your answer
Grade
*
Choose
6
7
8
9
10
11
12
Select who you would like to see
*
Mrs. Campbell, Last Names A-L
Mr. Anderton, Last Names M-Z
Reason for request **(NOTE: if you are thinking of hurting yourself or if you know of someone else in danger, please report immediately to a trusted adult in the school)**
*
Abuse
Anger
Anxiety/Worry/Stress/Depression
Attendance
Career/College Preparation
Family Issues
Friend(s)
Grades
Harassment
Something else - please describe below
Required
How are you doing right now on a scale of 1 to 10?
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This has to be the worst I have ever felt
1
2
3
4
5
6
7
8
9
10
I feel terrific!
What would you like me to know? Please give me an idea of what is going on.
*
Your answer
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