Request to see a Counselor Form - JMMS 2026-2027
This form will need to be completed for a student to see a counselor. Once complete, the Counseling Department will be notified and the appropriate person will call the student to come to the Counseling Dept. 
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Today's Date *
MM
/
DD
/
YYYY
Student's First and Last Name *
Student's Grade *
Person referring student *
Regarding  the question above, if you are a Staff Member or Parent referring a student, please list your name below. 
What is the concern?  *
How urgent does the concern feel?  *
not urgent
urgent
Is the student being harmed, having thoughts of self-harm, or harming others *
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