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SWCSD2 Wellness Program Information Form
All information provided will remain confidential and will only be disclosed to SWCSD2 Wellness Program Counselors. Content of this form will not be used for public knowledge.
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* Indicates required question
Email
*
Your email
Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Phone Cell
*
Your answer
Work Phone (optional)
Your answer
Preferred Form of Contact
*
Choose
Phone Call
Email
Text
Reason For Referral
*
Choose
School and/or Work Related Issues
Behavior Support
Undergoing A Big Change
Family Issues
Grief
Self Harm
Trouble Coping or Managing Emotions
Professional Development
Other
If you answered "other" on previous question, please provide brief description for the referral.
Your answer
What days and times are you available to meet?
Your answer
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