Sixth Grade Student Self Referral
I'm so glad you are reaching out to me! Please let me know a little bit about what is going on....
I am having concerns about...
Your first name and last initial
The name of my homeroom teacher is....
How big a concern is this for you?
Small but important enough to talk to you.
Urgent - someone is going to be hurt today
Before asking to see you, I have tried....
Working it out on my own
Talking with a friend
Talking with an adult at home
Talking with a principal or teacher
What is the best way to reach you?
Phone call (please give me your phone number in the blank for more info...)
What is the best time of day to reach you?
Is there anything else I need to know? If you want me to call you, I need your phone number. Please write it below.
Looking forward to speaking with you SOON!
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This form was created inside of Buncombe County Schools.