Ben Bolt-Palito Blanco ISD

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Request to see the Counselor

Use this form to see the counselor. A student can complete the form as well as a parent/guardian, teacher, principal, or classmate who has a concern for a student. The counselor will prioritize and visit with students as schedules allow. If there is an emergency or a student is in danger during school hours, pelase go to the office or call 361-664-9822 to report it to the principal or counselor. 

Student Grade*
Who is making the referral for this student to see the counselor?
Reason for the referral: How can the counselor help? (Check all that apply)*