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Waskom Middle School Counseling Referral
Please use this form to submit a counseling referral.
* Indicates required question
Email
*
Record my email address with my response
Student Name
*
Your answer
Grade
*
Choose
6th
7th
8th
Reason for counseling referral: Personal/Social
Anger Management
Bullying
Social Skills/Friends
Withdrawn/Shy
Honesty
Self-Esteem
Personal Hygiene
Family Conflict
Health (family or self)
Grief (loss/death)
Uncooperative/Defiant
Anxiety
Theft/Vandalism
Expressing Self-destructive Thoughts
Other:
Reason for counseling referral: Academic
Attendance
Underachievement
Homework
Study Skills
Organization
Goal Setting
Other:
Please briefly describe your concern.
Your answer
Urgency
*
needs immediate attention
is very important
can wait
Send me a copy of my responses.
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