Counselor Visit Request

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Need to talk something out? Not feeling quite like yourself? Concerned about a friend, your student or your child? Please fill out the form to visit with Mrs. Stokes or to refer someone for counseling. Remember, if you are very upset or if you or someone you know is not safe, ask your teacher to come to the counseling office right away. Mrs. Stokes will see you as soon as possible!

ahaley@blairoaks.org (not shared) Switch account

I am a: *

Student (If you are referring someone else, you are welcome to remain anonymous [secret]).

Teacher (teachers do not need to identify themselves. Counseling referrals can remain anonymous)

Parent (parents do not need to identify themselves. Counseling referrals can remain anonymous)

I am referring myself for a counseling visit. My FIRST and LAST name is: (skip if this doesn't apply to you).

I am concerned about someone else. Their FIRST and LAST names are: (skip if this doesn't apply to you).

My grade (or the grade of the person I am concerned about): *

6th

7th

8th

Other:

I need myself or the person I referred to see the counselor: *

As soon as possible. It's urgent!

By the end of the day (if possible)

By the end of the week

Is there anything else you want me to know about your or the other student's situation?

Submit

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