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Request to See the Counselor
This will be checked and responded to only during the school day. If it is an emergency and it is not during school hours, tell a trusted adult right away.
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* Indicates required question
Student Name:
*
Your answer
I am:
*
The student/self request
The teacher
A parent/guardian
Date:
*
MM
/
DD
/
YYYY
Grade:
*
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Required
Classroom Teacher:
Your answer
I am feeling:
*
1
2
3
4
5
6
7
8
Other:
I would like to talk with you about:
*
My school work
My family
My friends
Myself
My class
Something else secret or private
Tell me a brief description about our upcoming visit.
Your answer
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