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Student Request to see Counselor
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* Indicates required question
Email
*
Your email
Name (Last name, First name)
*
Your answer
Homeroom Teacher
*
Your answer
My concern is (check as many as you need)
*
Worried about school
Worried about home
Having trouble with another student
Having trouble with an adult
Trying to do better, but it is hard!!
Confused
Missing someone
Can't concentrate
College/Career Question
Question about schedule/classes
Other:
Required
What level is your concern?
*
Level 1-I could manage on my own through coping skills or adult input.
Level 2-I can wait to meet. It is a question about a class or friendship struggle.
Level 3-It is urgent but not an emergency. I'd like to see you by the end of the day (I am experiencing anxiety, sadness, or other feeling).
Level 4-I am, or a friend is, in crisis (suicidal ideation, self-harm, panic attacks or feeling unsafe about going home)
I need to see you... (RIGHT AWAY=BIG PROBLEM)
*
RIGHT AWAY!!
Sometime today
Sometime this week
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