Belmont Middle School Counselor- Contact Referrals 2024-2025

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Please fill out this form to request a meeting with your school counselor. We will get to you as soon as we can. Thank you!

Please remember: if your request pertains to a concern within a classroom regarding a peer, your best approach is to inform your teacher of your concerns first as discreetly as possible. If you've already done this, and you have not reached a resolution, please put in a referral.

IF YOU ARE FEELING SUICIDAL OR KNOW SOMEONE WHO IS FEELING SUICIDAL, PLEASE ASK TO COME TO STUDENT SERVICES IMMEDIATELY.

If you need help outside of school, please use the Say Something App or Website (https://www.saysomething.net/) or call the Suicide Prevention Lifeline: 988

Requests submitted after 2:30pm on a school day may not be responded to until the next school day

Email *

I am a: *

Student

Teacher requesting on behalf of a student

Teacher requesting to meet with a counselor to discuss a student concern

Parent requesting on behalf of my student

Parent requesting to have a counselor outreach me via phone (please note, due to privacy laws, we may only try to reach you via phone at the numbers listed in Powerschool)

Required

First and Last Name of Student/Person to be contacted: *

I am/my student is in the following grade: *

6th

7th

8th

Please read the following before answering the next question:

Please indicate to us the urgency of your counselor request by choosing from the following:

1: The request is not urgent - it can wait until the next school day or could even possibly be addressed/handled by another staff member, such as a teacher (i.e. scheduling questions/concerns, questions regarding other non-urgent matters, needing to talk about something that is causing minimal disruption/distress).

2: The request is somewhat urgent - I am requesting to speak with a school counselor before the end of the school day, if at all possible (i.e. needing to talk about something that is causing moderate disruption/distress, heightened worry/stress, sadness, or anger, or needing to bring something to a counselor/administrator's attention today).

3: The request is IMMEDIATELY URGENT - I am requesting that a school counselor drop what they are doing and speak with me NOW (this is reserved for genuine emergencies - such as concerns for your safety or the safety of someone else or another crisis-like situation; please only choose this for true urgent/emergent situations, as this might pull a school counselor from a class or from speaking with another student).

What type of request are you submitting? *

1: Not urgent

2: Somewhat urgent

3: IMMEDIATELY urgent

Briefly describe why you are requesting to speak with the counselors, so we have an idea of the concern: *

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