Scholar's Social Worker Support Form

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This form is designed for you to connect with the social worker to get help and support needed during this time of virtual learning.

The information you share will not be discussed with others except when you are at danger of harming yourself, others, or is unsafe. Please read the confidentiality statement included in the email that had the link to this form. There you will find a detail explanation of confidentiality and ways to protect your privacy.

Social worker will be in contact with you via phone or email. Zoom meetings can be scheduled.

Email *

First and Last Name *

Grade *

9th

10th

11th

12th

Phone number and Email address *

Why do you need support? (Check all that apply to you) *

I feel in danger and unsafe.

I need to talk about an issue or concern.

I want help with finding ways to get something I need.

I want a few scheduled times to meet with the social worker to learn specific skills.

I am interested in meetings in a small group with other scholars to learn specific skills.

Other:

Required

How are you feeling? (Check all that apply to you) *

Happy

Depressed

Stressed

Nervous

Lonely

Other:

Required

Give a short summary of your situation and why you need support. *

Would you like the Campus Minister to connect with you for spiritual support? *

Yes

Maybe

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