Counseling Service Self-Referral Form

Kinnikinnick C.C.S.D. #131

"Reaching for New Heights"

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Roscoe Middle School
Counseling Service Self-Referral Form

* Indicates required field

Name *

First

Last

Date *

Please provide a brief description of the concern you would like to discuss or problem solve: *

**If this is a crisis (abuse, neglect, threat of harm to self or others), please contact Mrs. Dean immediately. If she is not available, please contact Mrs. Cropp or Mr. Kaufman so we can ensure the safety of all students. The number is 815.623.2837.

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Roscoe Middle SchoolCounseling Service Self-Referral Form

Roscoe Middle School
Counseling Service Self-Referral Form