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Counselor Request Form
To see the Counselor, please complete this form just once. Mrs. Matthews will follow up with you as soon as possible.
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Email
*
Record my email address with my response
First Name
Your answer
Last Name
Your answer
Homeroom Teacher's Name
Your answer
Grade
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
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Reason for request- check the boxes that apply.
Problems with another student
Problems with schoolwork or homework
Personal
I am worried about my safety or someone else's safety
Other
Here is more information I want Mrs. Matthews to know.
Your answer
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