Request to talk with the School Counselor!
It's so good to hear from you! Please fill out this short form and I will be in touch as soon as possible.

Students: Parent/guardian permission is required for this request to be approved. Once permission is granted, Mr. Lankford will contact you as soon as possible.

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First Name *
Last Name *
Grade *
I would like to talk about: *
Required
How do you want to be contacted? *
When is the best time to be contacted? *
What is your phone number and/or email?
What is your parent/guardian's phone number and/or email?
If this is an emergency, please notify a trusted adult or an agency listed below.
Emergency is defined as someone is hurting you, you want to hurt yourself, or you want to hurt someone.

911
National Suicide Prevention Lifeline: 1-800-273-8255
Crisis Text Line: Text HOME to 741741 to connect with a Crisis Counselor
Burrell FREE 24/7 crisis assist team in Southwest Region:1- 800-494-7355

Informed Consent
As always, if you disclose someone is hurting you, you want to hurt yourself, or you want to hurt someone else, I will not be able to honor confidentiality. This means I may need to contact either your parent or make an outside agency aware of your situation.
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