Student Center Counselor Request System
Please complete this form so we can best prioritize your needs.
Student Id #
Who is your counselor? (See breakdown by grade & last name)
A-G Shane Cyphers
H-O Abby Bouchillon
P-Z Carrie Johnson
Transcript Request only
What is the purpose of your visit to the Student Center today?
Academic Counseling (schedule concerns/advising/graduation questions)
Social/Emotional Counseling (personal or relationship issues)
College/Career Counseling (exploring options, applying for schools/programs, scholarships)
My counselor called me down
Please rank your need to speak to a counselor on a scale of 1-5 so that counselors can prioritize your request.
1- I can be seen anytime
2- I would like to be see within a week
3- Important but not an emergency
4- Deadlines/Very Important-Urgent Matters
5- Emergency-Suicidal thoughts, abuse, self-harm or knowledge of others in danger-Please notify secretary that you need to be seen today!
I was called down
Please leave a short message about why you would like to see your counselor
Never submit passwords through Google Forms.
This form was created inside of Salem-Keizer Public Schools.