7th Grade Student Referral Form 2019-2020
This form is for students to request counseling services. Any information shared in this form is for the use of the school counselor and will NOT be kept in the any cumulative files. If you report any abuse, neglect, or intent to harm, then the Department of Children's Services at 877-237-0004 will be contacted; as appropriate.
Your Last Name, First Name *
Your answer
Your Grade *
Level of Urgency (Need) *
Which category best describes why you need to speak with me? (This helps me, help you...See examples below) *
OTHER (Anything not listed above - Explain).
Your answer
Tell me why you need to see me in detail based on what you choose above. *
Your answer
Have you talked to your parent/guardian about this situation?
HOW have you attempted to make the situation better?
Your answer
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