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Student Reservations
If you want to refer yourself or a friend who is having a problem please fill out this form and Ms. Priscilla will get back to you as soon as possible.
* Indicates required question
Full Name
(Of the person filling out the form)
*
Your answer
If you are referring a please write their name here
Your answer
Teacher Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Size of the problem
*
Small: This is not an emergency and can probably wait. This looks like "My friend didn't sit with me at lunch" or " Someone said something hurtful but I can work through it."
Medium: This is more serious and you need help by the end of the day. This looks like "I'm having a bad day, tried to solve it on my own but need more help"
Big: This is an emergency and you need help right now. This looks more like " My problem is too much for me to handle and is now affecting other parts of my life" such as big emotions or anxiety.
Required
What do you need help with?
*
Family
Friends/ Peers
My feelings/ emotions
School work
My Choices
Other:
Required
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