Counselor Assistance Form
This form can be used by a student, teacher or parent who needs to speak with a counselor.
Mrs. Bowser, Mrs. Capuchina or Mrs. Petty will respond to you as soon as possible.
What is your first AND last name?
Student's ID number?
Student's grade level?
Student's Homeroom Teacher
What does the student need help with?
Worried about school/grades
Worried about home/family
Having trouble with another student/friends
Having trouble with an adult
Dealing with big emotions
Describe the problem here. Please include the names of people and details if possible.
I need to speak to a counselor.... Reminder: This form is for non-emergencies only. If it is an emergency (thoughts of harming yourself), do NOT email a counselor. Call 911 or text HOME to 741741 or call National Suicide Prevention Lifeline: 1-800-273-8255
When you have time this week--it's not an emergency, but needs to be addressed
As soon as possible-- someone is harming or being harmed
I prefer to speak to the counselor...
Face to Face
What is your email address OR phone number?
Who would you like to speak with?
Mrs. Petty, 5th grade Counselor
Mrs. Bowser, 6th grade Counselor
Mrs. Capuchina, Counselor
First available counselor
This form is for non-emergencies only. If it is an emergency (thoughts of harming yourself), do NOT email your counselor. Call 911 or text HOME to 741741 or call National Suicide Prevention Lifeline: 1-800-273-8255. If you have immediate concerns for a child's safety and/or believe they are victims of abuse, please make a CPS report or call 911. Remember if you see something, say something. Please understand that confidentiality cannot be guaranteed in virtual meetings. De Zavala counselors will make every effort to ensure a confidential conversation, and as always, if she is concerned you may harm yourself or others, or that someone is causing you significant harm, she will notify the appropriate persons.
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This form was created inside of PasadenaISD.