Student Self-Referral Form
Use this form if you want/need to speak to a counselor.
Your Last Name
Your First Name
Your grade level
Best class to contact you
I need to talk about
URGENT!! I need to speak to someone right away!
Illness or loss of a family member or friend
I am worried about a friend.
Relationship with a friend/peer.
Relationship with an adult (family or teacher).
I want to feel better about myself.
Someone is bullying me.
I think I may be a bully myself.
Dealing with peer pressure to do things I do not want to do.
My grades and schoolwork.
Planning for the future (career, college, scholarships, etc.)
Something else - I will tell you when I see you!
Dual credit question.
Flex work question.
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This form was created inside of Aurora R-8 School District.