Muirlands Middle School Request to Meet with My Counselor Form

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Hello Dolphins,
If you would like us to contact you (student or parent) please complete the following questions.
Please remember that if this is a medical/mental health emergency to please call 911. We will be checking the responses on this form daily but give us 24-48 hours to reach out.
We would also like to remind you that school counselors practice confidentiality when working with students, everything discussed is confidential unless it is disclosed that a student/person has plans to hurt themself, others, or someone is hurting them (physically, emotionally, and/or sexually).

Email *

Student's First and Last Name *

Grade? *

Please provide the phone number / email you would like us to reach you at: *

What topic would you like to talk about: * *

Academic: Grades, Assignments, Classes, Etc

Social-Emotional: Feelings and any other concerns you have regarding social/emotional situations

College/Career inquiries

Other

Required

Please provide us a short summary of what your concerns are. *

I understand that the school counselor may not receive this request immediately if this is a crisis please contact emergency services at 911. I also understand that anything discussed with the school counselor or anything my student discusses with the school counselor is confidential unless I or my student discloses that they want to or are hurting themselves or others or is being hurt physically, emotionally, or/and sexually. * *

I agree, and understand

Required

Send me a copy of my responses.

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