Guidance Counselor Interview Form
Document and assess student needs, set goals, and plan actions during counseling sessions.
Student Full Name
*
First Name
Last Name
Student Grade Level
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Other
Student Email Address
example@example.com
Student Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Counselor Name
*
First Name
Last Name
Date and Time of Interview
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Interview
*
Academic Performance
Behavioral Concerns
Social/Peer Issues
Emotional Well-being
Career/College Planning
Other
Areas Discussed During Interview
*
Academic Progress
Attendance
Behavior
Social Skills
Emotional Health
Family Issues
Future Planning
Other
Assessment of Student Needs
*
Rows
Not a Concern
Minor Concern
Moderate Concern
Major Concern
Academic Issues
1
2
3
4
Behavioral Issues
5
6
7
8
Social/Peer Issues
9
10
11
12
Emotional Well-being
13
14
15
16
Family/Home Situation
17
18
19
20
Goals Set During Interview (List specific goals agreed upon)
*
Action Plan/Recommendations (Describe steps to be taken, referrals, or follow-up actions)
*
Additional Comments or Notes
Signature of Counselor or Student (as applicable)
*
Submit Interview
Submit Interview
Should be Empty: