2021/2022 CEMS Counselor Request Form

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Please use this form to request to see a counselor. If this is an emergency (any safety concern for yourself or others) you need to ask your teacher to get in contact with a counselor right away.

First Name and Last Name *

Which team are you on? *

Why are you requesting to see a counselor today? Check all that apply. *

Issues with friends

Scheduling issue (Change classes, same class twice)

Problems at home/with family

I'm stressed out/feeling nervous

I'm feeling sad/depressed

I'm mad/angry

People are making fun of me

I'm worried about my grades/getting my school work done

Issue with a teacher

Other:

Required

Comments

Thank you!

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