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Student's Name
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Teacher's Email
*
I would like this child to meet with the school counselor for the following area(s) of concern
*
Academics
Adjustment to school
Self-Esteem
Behavior
Death/Grief
Anxiety/Stress
Friendship Issues
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Anger
Please briefly describe the area (s) of concern
*
As a staff member I have :
*
Conversed with the Child
Discussed with the Principal
Telephoned Home
Discussed with the counselor
Met with the Parent (s)
Submit