Note to Counselor
Student Self-Referral to Counselor
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What is your name? (FIRST and LAST name, please) *
What grade are you in? *
Who is your homeroom teacher? *
Would you like to.... *
What would you like to talk about?
*Please choose at least ONE thing.
When would you like to talk? *
Is there anything you would like to tell me before we meet?
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