Request to See My Counselor 22-23

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Last Name *

First Name *

Grade *

6th

7th

8th

My Need is: *

Red (Urgent: I need to see you today.)

ORANGE: (Important: I could wait for a day or two).

YELLOW: (More long term: I could wait until next week).

Type of Concern *

Class Issue

Friend Issue

Family Issue

NO MORE SCHEDULE CHANGES

Emergency

Need a space to cool off/calm down

I was called to the counseling office

Other:

The best time to meet? (Select all that apply) *

1st period

2nd period

3rd period

4th period

5th period

6th period

7th period

8th period

Study Hall

Lunch

Before school

Other:

Required

My counselor is *

Mrs. Franco (Last Name A-G)

Mrs. Culp (Last Name H-O)

Mrs. Maloney (Last Name P-Z)

Other:

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