Student Self Referral
I need to talk to you about...
Friends - Social
Feelings - Emotions
My first name and last initial
The name of the teacher I have right now is....
How big a concern is this for you?
Small but important enough to talk to you.
Urgent - someone is going to be hurt today
Before asking to see you, I have tried....
Working it out on my own
Talking with a friend
Talking with an adult at home
Talking with a principal or teacher
Is there anything else you want me to know?
I will try to come and get you as soon as I can. Please know that there are other students who also need to see me as well as other obligations I have. Thanks for filling out this form. I hope we can work together to help you feel better about what is going on for you.
Send me a copy of my responses.
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