Moore Counseling Request Form
Who is filling this request out? *
If Parent/Guardian provide email (REQUIRED)
First Name (As listed in Infinite Campus)
Last Name (As listed in Infinite Campus)
Health Science Academy
Bullying/Threat/Reporting Self Harm?
Please include a statement here.
Please indicate the reason you need to speak with a counselor:
Academic Concern (Pathway change, Graduation concern)
Personal Issue (Bullying, Drama, Home/Family, Grade)
Letter of Recommendation
Please include comments pertaining to above selected issue:
This will help us to assist you more effectively.
Please read and check the boxes below:
In the case of an emergency I understand that I need to find an adult immediately.
I understand it can take up to 48 hours for a Counselor to get back with you.
I understand I need to check my EMAIL on a regular because a Counselor may respond to my request via email. (Parents the email you provided)
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This form was created inside of Jefferson County Public Schools.