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Student Visit
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* Indicates required question
Student ID
*
Your answer
Student Gender
*
Female
Male
Other:
Student Grade Level
*
9
10
11
12
Other:
Reason for Visit
*
Schedule Change
Academics
Attendance
College
Career/Job
Parent/Caregiver/Legal Guardian meeting
New student enrollment
Conflict with teacher/staff
Conflict with student
Needed break from class
Anger concerns
Anxiety/Stress concerns
Bullying concerns
Family/home concerns
Grief/loss concerns
Sadness concerns
Self-care (sleep, hygiene, etc.) concerns
Safety concerns
Other:
Required
Referred By
Summons by counselor
Self
Teacher
Parent/family member
Administrator
Peer
Office staff
Health office
Campus security
Anonymous
Other:
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