Muirlands Middle School Request to Meet with My Counselor Form
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).

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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: * *
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. * *
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