Shanks Mail- Parent/Guardian Counselor Referral Form
Parent/Guardians,
It takes a village! Please fill out this form if you would like the counselor to meet with your LEAD student regarding a problem or just to check in. I appreciate your support in helping our students reach their full potential!
Have a great day!
~Mrs. Shanks
Email address *
Student Name *
(Last, First)
Your answer
Grade
Date *
MM
/
DD
/
YYYY
Time *
Time
:
Referring Parent/Guardian Name *
Your answer
Academic Reason for Referral
(Check all that apply)
Social/Emotional Reason for Referral
(Check all that apply)
He/She needs to see Mrs. Shanks...
I would like Mrs. Shanks to contact me. *
The best time of day to contact me is:
The best phone number to reach me is...
Your answer
A copy of your responses will be emailed to the address you provided.
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