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Counselor Request Form
If you have a concern or question that you would like to talk to Ms. Jeter about, fill out this form and she will email you about setting up a time to meet.
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* Indicates required question
What zone are you in?
*
Blue Zone (sad, sick, tired, bored)
Green Zone (happy, calm, ready to learn)
Yellow Zone (worried, sacred, annoyed, frustrated)
Red Zone (angry, terrified)
Your name
*
Your answer
Your grade
*
Kindergarten
First grade
Second Grade
Third Grade
Fourth grade
Fifth grade
Your teacher's name
*
Your answer
The kind of problem your having
*
Friends
Family or Home
School
Big feeling
Other
Required
What have you done to help make your problem better?
*
Your answer
Please fill in the phone number or email you would like Ms. Jeter to reach you at to set up a time to talk.
*
Your answer
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