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Counseling: Student Self-Referral

The purpose of this form is to offer you the opportunity to seek out support if you need to talk to an adult. Your email will be recorded so we know who to reach out to.

Required fields marked *

Please enter your Email address. *

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First Name*

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Last Name*

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When would you like to check in with a counselor?*

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Sometime this week.

Sometime today or tomorrow.

As soon as possible.

What do you want to talk about?*

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Family

Friends

Schoolwork

My feelings

My choices

Other:

Please briefly describe the issue. *

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If you would like to meet with anyone in particular, please list their them here.

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Confirmation Email

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