CLMS Counseling Department Appointment Request Form
Complete this form to request a meeting with a school counselor.
* Required
Email address
*
Your email
I am a
*
Student
Parent
Teacher
Other:
Name of Person Referring, if not the student
*
Your answer
Student's Last Name
*
Your answer
Student's First Name
*
Your answer
Student's Grade
*
6th
7th
8th
Reason for Meeting Request
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Academic Concerns
Social/Emotional Health
Attendance/Truancy
Refuses to follow instructions
Poor Hygiene
Suspected Abuse/Neglect
Inadequate Peer Relations
Gossip/Rumors
Sexual Harassment
Bullying/Cyberbullying
Other:
Please provide a short explanation. (This google form is not a confidential communication method)
*
Your answer
List phone number and email address. Students, please use your school email.
*
Your answer
Would you like a virtual conference?
*
Yes
No
Please select Your Counselor
*
Mrs. Dean (All students last names A-K) 770-385-6889
Dr. Pennington (All students last names L-Z) 770-784-4993
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