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2023-2024 AEMS Student referral
Use this form if:
- You would like to schedule a check-in meeting with a counselor
- You are a student and you are worried about yourself or someone else
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* Indicates required question
Email
*
Your email
Is this referral for yourself or someone else?
*
Choose
Myself
Someone else
Enter your name or the name of the person you are worried about
*
Your answer
Student's Grade
*
Choose
7th
8th
What is the best way to get in touch with you? Enter your number or email:
Your answer
Does anyone know about this issue? If yes, who is that person?
Your answer
Type of concern
*
My grades or school work
Having trouble with technology
Food, clothing, housing
My mental health or a friend's mental health
My health or someone else's health
Other:
Required
How soon do you need to speak to someone?
*
It can wait a couple of days
1
2
3
4
5
It's very urgent
Submit
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