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Name
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First Name
Last Name
Email Address
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required
Date
Must contain a date in MM/DD/YYYY format
Who would you like to see?
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required
Administrator
Counselor
Nurse
Which administrator do you prefer?
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required
Principal Ruder
Assistant Principal Pittman
Assistant Principal Munson
What would you like to talk about with an administrator?
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Which counselor would you prefer to see?
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required
Counselor Adwell
Counselor Swezey
Is your concern an emergency?
Yes
No
Maybe, I'm not sure
Grade and Team
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required
6 Black
6 Silver
7 Black
7 Silver
8 Black
8 Silver
What would you like to talk to the counselor about?
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required
Select at least one topic
Academic help (grades, schedule, teachers, Xello, etc.)
Anxiety
My mental health
Home life / family concern
Peer / social issue
Friendship issue
Self improvement / personal issues
Hot Pass
Other
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Please specify any other topic
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What is your reason for needing to see the nurse?
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First aid / injury
Illness
Bathroom / hygiene
Other
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Please tell us the other reason for wanting to see the nurse
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What is the last name of the teacher in the class where you are now?
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What is the last name of the teacher whose class you will be in next?
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