STUDENT -- School Counselor Request
Thank you for taking the time to complete a Counselor Request Form, please provide as much information as possible and we will get back to you as soon as possible.

Thank you!

Student First Name: *
Your answer
Student Last Name: *
Your answer
Student ID: *
Your answer
Grade: *
Do you want to talk to someone specifically? *
Reason(s) for Referral (please check all that apply): *
Tell me more about the problem(s) / concern(s): *
Your answer
Urgency of the issue(s): *
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