Student Center Counselor Request System
Student Id #
Who is your counselor? (See breakdown by grade & last name)
9th A-LE Mr. Lane
9th LO-Z Ms. Piras
10th A-L Mrs. Bath-McDonald
10th M-Z Ms. Piersma
11th A-FU Mrs. Strong
11th G-ME Mrs. Antunez
11th MB-PA Mr. Duran
12th A-GAN Ms. Strong
12th GAR-MA Mrs. Antunez
12th MB-PA Ms. Piersma
12th-PE-Z Mr. Duran
What is the purpose of your visit to the Student Center today?
Academic Counseling (schedule concerns/advising/graduation questions)
Social/Emotional Counseling (personal or relationship issues)
College/Career Counseling (exploring options, applying for schools/programs, scholarships)
Please rank your need to speak to a counselor on a scale of 1-5 so that counselors can prioritize your request.
1- I can be seen anytime
2- I would like to be see within a week
3- Important but not an emergency
4- Deadlines/Very Important-Urgent Matters
5- Emergency-Suicidal thoughts, abuse, self-harm or knowledge of others in danger-Please notify secretary that you need to be seen today!
Please leave a short message about why you would like to see your counselor
Send me a copy of my responses.
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This form was created inside of Salem-Keizer Public Schools.