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Student Request for School Counselor
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* Indicates required question
My name is...
*
Your answer
What grade are you in?
*
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Today's date is...
*
MM
/
DD
/
YYYY
My teacher is...
*
Your answer
I would like to talk about...
*
My schoolwork
My homework
My family
Myself
My class
My friends
Something private
Other:
How soon would you like to see me?
*
Today
Tomorrow
This week
Any other questions or comments?
Your answer
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