Check in Form

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Check in Form

FIrst Name *

Last Name *

List two adults that you trust to talk to when you are struggling *

Are you struggling extreme stress/ anxiety or depression? *

Yes

Are you worried about one of your friends who are struggling with Extreme stress/ anxiety or depression? *

Yes

If you answered Yes to any of the questions above, please tell an adult! *

I have told an adult about this

I will tell an adult

I need to talk to Mrs. Groeneweg asap

Required

Is there anything else you would like to share with Mrs. Groeneweg at this time? *

Please take a picture or write down the information below! *

Call: 1-800-273 TALK (Yes I took a picture or wrote down this number)

TEXT: "I care" to 898211 (Yes I took a picture or wrote down this number)

CAll 211 Helpline (Yes I took a picture or wrote down this number)

If emergency call 911

Required

Mrs. Groeneweg thinks you are amazing!

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