Counselor Request Form
Please complete this form to see Ms. Peterson or Ms. Gylys
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This form is only monitored during the school day. 

* If it is after 3pm, a non-school day, or a weekend and you need immediate help, please ask an adult for help and use the resources below *

- 911  
- Mobile Crisis (888)573-1006 
- Suicide and Crisis Lifeline, call or text 988
- Say Something 24/7 anonymous reporting system
Name: First and Last  *
Grade
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I am having concerns about...
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How big of a concern is this for you? 
1: Small, but important enough to talk with you about it
5: Big, if I can't be seen, please call my parent/guardian to tell them I'm in a rough spot
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Before seeing a counselor, I have tried...
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What would you like me to know about what is going on for you?
A counselor will try to see you as soon as they can. Please understand that there are other students who also need to see a counselor, and the counselors also have other duties at school as well. We look forward to connecting with you!
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