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24-25 AJB Counselor Request Form
Fill out the information below and submit/Rellene la siguiente información y envíela.
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* Indicates required question
Email
*
Your email
Who is making the request?
*
Student
Staff
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's ID #:
*
Your answer
Counselor Requested (Luna A-L), (Garza M-Z), Communities In Schools (Valencia)
*
Valencia (CIS)
Garza (M-Z) Alpha
Luna (A-L) Alpha
Reason to speak with counselor
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Student Conflict
Academics (Attendance, Failing Grades, Study Skills, Organization, Homework, etc.)
I heard something or just saw something and would like to tell an adult
Grief/ Loss
Bullying
Test Anxiety
Social/Emotional (Anger Management, Social Skills, Withdrawn, Self-esteem, Anxiety, Defiant, Personal Hygiene, etc.)
Schedule Conflict
Family Concerns
Personal Issues
Peer Mediation Request
Other:
If this is a staff referral, please include your name.
Your answer
Student needs to see you:
*
Right away!
Sometime today.
Sometime this week.
Comments: Anything that will be helpful for me to know ahead of time:
Your answer
Send me a copy of my responses.
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