Counseling Form

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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 (w/Maggie intern & Tony) 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

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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