STUDENT School Counseling Referral Form
Please complete this referral and submit.  Mrs. Pike will call for you when she is available.  If you have an emergency (you or someone else is in immediate danger), please let your teacher know so Mrs. Pike can be notified immediately.
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Student Name (first and last) *
Grade *
Teacher *
What would you like to see the school counselor about? *
What are some things you have already tried to help you with this problem? *
When do you need to see the counselor?  Emergencies should be reported to your teacher. *
Submit
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