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School Counselor Request Form
For: Parents/Guardians & Staff
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* Indicates required question
Email
*
Your email
I am a:
*
Parent/Guardian
Staff Member
Other:
Your Name:
*
Your answer
Student's Name:
*
Your answer
Grade Level
*
9th
10th
11th
12th
Concern/Reason(s) for Referral (check all that apply):
*
Academic concerns
Home life concerns
Friends concerns
Mental health concerns
College/Career/Goal Planning
Needs help with organization & time management
Social skills/making friends
Other:
Required
How urgent is this referral? *If you think the student is at risk of harming themselves or someone else, contact Mrs. Jenkins or Administration immediately. Do not fill out this form.*
*
Not Urgent
1
2
3
4
5
ASAP
What would you like the counselor to do:
*
observe this student
to discuss concerns with me
to meet with the student
Required
Notes for Mrs. Jenkins:
Your answer
Submit
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