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School District of Desoto
DMS Guidance Referral Form

Student Self-Referral Form for Counseling Services

 Dear School Counselor,


My name is: *
I am in grade:
6  7  8  
My homeroom teacher is:
My Student ID is:
I need to talk to you about (click all that apply): *
URGENT!!! Something private right away!!!  
The death of a person or a pet that I love  
A friend I am worried about  
My angry feelings  
How to get along better with friends/peers  
How others are treating me  
Feeling better about myself  
Saying "NO!" or "STOP IT!" when people want me to do things I don't want to do  
My grades and schoolwork  
Planning now for the future  
Something else  
Other comments:


Please click the [Submit] button below when you are done, and someone in guidance will get with you as soon as possible.

Your Name:*
Your E-mail:*
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