Student Request for Counseling - Grijalva
Mrs. Grijalva welcomes PJH students to fill out this form any time you feel like you need to see me. Just let me know what's going on and I will call you down to our office as soon as I can. Everything you enter here is kept confidential!
Student Name (First and Last)
"I would like to talk to you because . . . "
Check all that apply and please know that anything you say on this form will remain confidential!
I'm having issues with my school work
I'm having issues with my family or home life
I'm having issues with friends
I'm having personal issues
I'm having trouble with another student
I'm feeling confused
I'm missing someone
Brief description of concern above:
I need to see you . . .
Please know we will always do our best to see you as soon as we can. Sometimes we are in meetings with other students or parents and cannot see you right away.
As soon as you can!
Sometime this week please
Whenever you can
I will come by before school, after school or lunch on my own (I just want you to know I will be coming!)
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