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.
Student First Name:
Student Last Name:
Do you want to talk to someone specifically?
No, I don't have a preference
Yes, My counselor (Mrs. MJ: last names A-L; Dr. Frazier: last names M-Z)
Yes, Ms. Maureen
Yes, Mr. Nathan
Yes, Mrs. Reynolds
Yes, Mr. Montoya
Reason(s) for Referral (please check all that apply):
Academic Concern (Have you reached out to the teacher, this should be your first step)
Grades (Have you reached out to the teacher, this should be your first step)
Study skills / habits
Teacher or Class concern(s)
Social issue / friend(s)
Bullying (Please provide more information below in Summary)
Death / Grieving
Middle School or High School Question
Career and College Info
Tell me more about the problem(s) / concern(s):
Urgency of the issue(s):
Urgent (you're fearful of your safety or others are at risk of being harmed)
BIG issue - Needs to be seen right away (time sensitive issues, death / grief, bullying, extreme sadness )
small issue - Issue is not major, (but you would like to get help solving or coping with it)
Not Urgent - Issue is not time sensitive (example... high school question when you are in 6th grade, college question)
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