School Counseling Intake Form
Please fill out this form to help us understand your needs better.
Student Information
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade Level
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
Reason for Counseling
Current Concerns
Academic Performance
Excellent
Good
Average
Needs Improvement
Social/Emotional Concerns
Previous Counseling Experience
Yes
No
If yes, please describe:
Additional Information
Submit
Should be Empty: