SVHS Student Counselor Request

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Please fill out the following form to confidentially request to see your High School counselor. Your response will be sent via e-mail to Mrs. Luplow Monday through Friday 7:30 - 2:30.

This form is for non-emergencies only. If it is an emergency, reach out to a reliable adult, visit the counselor web-page for text-lines or hotlines, or call 911 in the event of a medical emergency.

Email *

Last Name *

First Name *

What is your current grade level? *

9th Grade

10th Grade

11th Grade

12th Grade

Required

How would you like to meet? *

Face to Face at School

A phone conference (if by phone - counselor will contact your parent to reach you)

I would like to talk to my counselor about *

School

Myself

Friends

Family / Home

Future Planning

Scheduling

Other

How urgent is your request *

As soon as possible. It's urgent

See me within the next day or so.

See me sometime this week

Any other information you would like me to know? *

Confidentiality Statement

**What you tell Mrs. Luplow is confidential (between you & I), unless...
1. You tell me you are going to hurt yourself.
2. You tell me someone is going to hurt you.
3. You tell me you are going to hurt someone.
4. You tell me something like "I can't see the board in math class!"
**In other words, I only need to share the details of what we talk about if your wellbeing is at stake. I do this because I care and because I am legally bound to do so. I will always do my best to let you know before I share anything we talk about so it isn't a surprise to you.**

Send me a copy of my responses.

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