Small Group Counseling Request Form

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The Medlock Bridge Elementary Counseling department believes in the personal potential of every student. I am pleased to offer several small group counseling opportunities throughout the year to assist students to reach their full personal and academic potential. All groups are confidential.

Student Name *

Grade *

Homeroom Teacher *

Group Consideration *

Parent/Guardian Name *

Parent/Guardian Phone Number *

Parent/Guardian email address *

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