Request to See A Counselor
This is a request to see Ms.Moffitt. Requests will be answered in the order in which they are received. Please do not put in multiple requests for the same issue. Thank you for your patience, I will get back with you as soon as I am able.
Name (Last Name, First Name)
Which counselor have you been seeing? (check all that apply)
Mrs. Ali (A-L)
Mrs. Hill (M-Z)
Ms. Moffitt (Behavior Specialist)
Ms. Massicci (Social Worker)
My problem is… (check as many as you need)
Worried about school
Worried about home
Trouble with another student
Trouble with an adult
I keep getting in trouble
Trying to do better but it’s hard!
Problem not listed
I need to see you…. (I will make every effort to see you as requested. If this is an emergency please tell your teacher/come to the Counseling Center).
RIGHT AWAY (HARM TO SELF OR OTHERS)
Sometime this week
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