School Counseling Student Self Referral
I Need to see the school counselor!
Name *
Your answer
Homeroom Teacher *
Your answer
Date *
MM
/
DD
/
YYYY
Pick One *
The area of concern that I have is based on *
I have tried to solve the problem myself *
Required
I cannot walk away or let it go *
Required
This is still going to be problem tomorrow *
Required
My teacher is aware of the problem *
Required
My parent(s)/ guardian is aware of the problem *
Required
On scale of 1 to 5 rate the severity of this problem *
Not Very Severe
Very Severe
Submit
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