Social Work Student Request Form
Thank you for requesting to see me. Please fill out this form to the best of your ability. I will work to see you in a timely manner. 
-Ms. Waters 
Confidentiality
Please understand that what is discussed will remain confidential unless:
1. You disclose that you are/have plans to hurt yourself or someone else
2. You disclose abuse (physical, emotional, and/or sexual) or neglect
3. You disclose threats to the safety of the school
4. If you give me permission to share
Email *
Date *
MM
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DD
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Name (First and Last) *
Grade *
I would like to meet with you to discuss... (Check all that apply) *
Required
Brief description of your problems or concerns *
Level of severity: *
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