MSA - School Counselor Request for Mental Health Support (for Students and Parents)       **ONLY DURING SCHOOL CLOSURE**
Hello MSA Family! We know this is a very difficult and stressful time for many of our students and families. Since we are not able to see everyone on a daily basis, we wanted to provide this opportunity to ensure that our students and families are safe and have everything that they need! Additionally, want to take this time to provide you with a chance to reach out to your school counselor if your student is dealing with mental health challenges during this time. If a student is feeling overwhelmed and/or is in need of emotional support from their counselor, please take a few minutes to complete this form. Note: This form can be filled out multiple times, so please feel free to complete as needed. SPECIAL NOTE: Counselors are  only able to speak to students concerning non-emergency matters. IF YOUR STUDENT IS IN DANGER OR THREATENING TO HARM HIM/HERSELF, PLEASE CONTACT CENTERSTONE'S MOBILE CRISIS UNIT AT (941) 782-4150 OR DIAL 911.
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Email *
What is your relationship to the student? *
Required
Your Last Name *
Your First Name *
Your Phone Number *
Student's Last Name *
Student's First Name *
Student's Phone Number *
Student's Grade Level *
Required
Briefly state your concern to let us know how a school counselor can assist the student today.  A counselor will contact the student as soon as possible. *
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