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Student Request to see the Counselor
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* Indicates required question
Name (First and Last Name)
*
Your answer
Grade
*
Second
Third
Fourth
Fifth
Other:
Required
Homeroom Teacher
*
Mitchell
Piner
Ross
Jefferson
Cates
Carten
Raymond
Scanlan
Wilkes
Stevenson
Faircloth (Roe)
Lilly
Person
Larrabee
Cowart
Mattis
Phillipps
Bird
Stone
Stephens
Other:
Required
I need to speak with the counselor about....
*
Check as many as you need.
School
Home
Friends
Having trouble with another student
Having trouble with an adult
Other:
Required
I need to see you.....
*
Right away= Big Problem
Right Away (Emergency= Big Problem)
Within a 1-2 days (Very Important= Medium Problem)
By the end of the week (Little Problem)
Required
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