JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Request for Student Counseling
If you feel your student would benefit from visiting with me, that's great! I understand that it can be hard to reach out directly so feel free to fill out this form
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Your name and relationship to student
*
Your answer
Can I contact you for follow up?
*
Yes
No
Student's name
*
Your answer
Student's Grade
*
Choose
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Freshman
Sophomore
Junior
Senior
Concern area
*
Social (making friends, bullying)
Emotional (grief/loss, anxiety, acting out of character)
Academic (grades, outside opportunities)
Required
Feel free to leave any details here
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of State of South Dakota K-12 Data Center.
Report Abuse
Forms
