Counselor Referral Form

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This form is to request an appointment with Mrs. Crowder, the Middle School Counselor at Piedmont Community Charter School.

If you have a medical or life threatening emergency that occurs outside of school hours please call 911 to request immediate help. If you or someone you know is having a mental health crisis, please contact Partners Behavioral Health Management HOPE Line for Gaston County at 1-888-235-4673, or text the word HELP to 741741.

Student First Name *

Student Last Name *

Email:

Student Grade Level *

5th

6th

7th

8th

What is the primary reason you would like to see the counselor? *

Academic (course planning, a specific class, study skills, grades, etc.)

College & Career Prep (Career Exploration, Personal Interests & Abilities, College Exploration & Readiness)

Personal/Social (Something about yourself, or someone you'd like to discuss, Goal Setting)

I am a: *

Parent/Guardian

Student

Faculty/Staff Member

Other:

Please write a brief comment regarding your concern: *

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