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Delshire: Counseling Appointment Request
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Email
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Your email
I am the:
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Student
Parent
Teacher
Student's Name
*
Your answer
Student's Grade
*
K
1
2
3
4
5
Student's Teacher
Your answer
Parent's Name
Your answer
Reason for Referral
*
Anger/Conflict
Behavior
Social Skills/Friends
Personal Hygiene
Teacher Request
Depression/Anxiety
Health/Wellness
Grief/Loss/Death
Family
Self-Esteem
Bullying
Academics
Other:
Comments
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