What's Up? Self Referral Form/¿Que pasa? Formulario de auto referido.
If you have something going on, or know of something going on or know of something going on with a friend that you would like to share with a Counselor, Teacher or Vice Principal fill out this form. All responses are confidential (that means no one sees them but the counselor!) If there is an emergency (you are having thoughts of suicide or self-harm, or are otherwise in danger), you do not have to fill out a request- let an adult know and come straight to the office!

Si a usted le sucede algo, o sabe que algo sucede con un amigo que le gustaría compartir con un consejero, maestro o subdirector, complete este formulario. Todas las respuestas son confidenciales (¡eso significa que nadie las ve, unicamente el consejero!)
EN CASO DE EMERGENCIA (SI TIENE PENSAMIENTOS SUICIDAS O DE HACERSE DANO, O CUALQUIER OTRO PELIGRO)
NO TIENE QUE LLENAR UNA PETICION - AVISE A UN ADULTO QUE QUIERE VENIR A LA OFICINA DE LA CONSEJERA.


Date: *
MM
/
DD
/
YYYY
Last Name/Apellido *
Example: Cruz, Tom/ Ejemplo: Cruz, Tom
Your answer
First Name /Nombre *
Example: Cruz, Tom/ Ejemplo: Cruz, Tom
Your answer
Lunch #/Numero para la comida *
Example: Cruz, Tom/ Ejemplo: Cruz, Tom
Your answer
Grade/Grado *
Who do you want to talk to? /Con quien quieres hablar? *
I need to talk to you about.../Necesito hablar contigo acerca de... *
Required
Submit
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