Student Self-Referral Form Student Self-Referral Student Self-Referral for counseling services through Catholic Charities This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.About YouYour Name(Required) First Last Grade Level(Required)7th8th9th10th11th12thHomeroom TeacherWhen can we meet? Do you have a study hall or other time during the time that you can meet?Your Email Address(Required) Email Address Confirm Email Address I would like to see you about: (select at least one)(Required) Grades/ Schoolwork Bullying Self-esteem Loss or grief My feelings/ behaviors (anger, anxiety, concentration…) My choices Relationships (friends, family, other) I’m concerned about someone else Something private Other/something else (please describe below) Are there any other details that you would like me know before we meet? Δ