Wellness Walk-In Form
We understand that sometimes you might not know if you would like speak with someone or you may not be sure where to start. That is completely okay! We are here to help walk you through it and answer any questions you might have if you are hesitant about anything. Answer what you feel comfortable with below and we'll go from there.

Thanks for coming by!

- Miss Brittany
(School Counselor / Mental Health Professional)

- Miss Megan
(School Counseling Intern)

Confidentiality: What you say in here stays in here!
Unless...
someone is hurting you.
you want to hurt someone.
you want to hurt yourself.
you give permission to share with another trusting adult.

Sign in to Google to save your progress. Learn more
Email *
Student's First and Last Name *
Grade
Clear selection
How are you feeling today?
Captionless Image
Clear selection
We have different services that we can offer you. Please select the one(s) that best fits your needs. (You may choose more than one)
Please select the reason(s) why you would like to talk to a Mental Health Professional today:
On a scale of 1 to 5, how urgent is this for you?
Not urgent
Very urgent
Clear selection
Is this your first time meeting Miss Bounds or Miss Aikawa?
Clear selection
Any other comments and/or questions?
Thank you!
Thank you so much having the courage to share this information with us! We will contact you shortly. ~CMS Wellness Center
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of ABC Unified School District. Report Abuse