Guidance Counselor Contact Request Forms

School Counselor Appointment Request form for Students

Printable Request Form to complete and deliver to the Middle School office

Online Request Form

Complete and submit this form to request an appointment with the counselor. Be sure you answer the security question at the end of the form before you submit.

Student's Name and Grade Level

Today's Date

Email address

Which hours do you have elective classes? Eg. Band, Choir, PE, Health, Writing, Exploring Math, Impact for Success, Computers or a foreign language

Academic/Grades related reasons you would like to see Ms. Creutz. Please check all that apply. Homework Teacher conflict Grades/test scores

Social/Friend related reasons you would like to see Ms. Creutz; Check all that apply Friend Issues Bullying or being bullied Other social issues

Family related reasons you would like to see Ms. Creutz: Please check all that apply. Family is going through changes. Other family issues

Other reason you would like to see Ms. Creutz Something not listed

Please explain in words the issue:

Ms. Creutz will meet with you as soon as possible.

Security Check - To verify you are not a robot, please answer this question:

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