EmailMeForm
Counseling Request Form
Please use this form to refer students (or yourself) to the School Counselor. You can use this form anonymously by simply not filling out the "person referring" information.
Information provided in this form is confidential.
Name of student BEING referred
First
Last
Student Grade Level
Please select
PreK
TK
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of Person Filling out this form
First
Last
Your Email
If you would like the School Counselor to contact you for more information, you must provide either your email or phone number.
Your Phone Number
###
-
###
-
####
If you would like the School Counselor to contact you for more information, you must provide either your email or phone number.
Please check all that apply.
Academic Concern
Personal Concern
Spiritual Concern
Other
If you choose other, please be sure to give more information in the comment section.
Priority Level
Please select
Low
Moderate
High
PLEASE EXPLAIN the situation you are concerned about. Try to provide as many details as possible to help us efficiently serve the student.
PBS Teachers, if you have a suggestion for guidance lesson/group counseling, please list it here.
