Counseling Form
Please fill out this form if you are interested or in need of a check in. these will be available via sign ups/drop-ins and will take place on Mondays for middle schoolers from 4-8:30pm (w/Sarah M.Ed), Tuesdays from 6-8:30pm with Tara & Stephanie for teens, and Fridays for all ages (11-23) (w/Stephanie, LMHC) and as needed during the week. 

Someone will follow up with a confirmation email. 

If you are in need of immediate support, please call Elliot Emergency Services at: 800-988-111
or the Trevor Project: Text START to 678-678
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Name/Pronouns *
Age *
Email *
Be sure to provide an email address that you use often, as this will be how we confirm the check in. 
Please provide a brief summary of why you are requesting a check in?  *
Be sure to provide an email address that you use often, as this will be how we confirm the check in. 
Emergency Contact, name & phone number *
Must be a parent or guardian and must be a name and phone number 
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