Student Counseling Interest Form
St Matthias School guidance counselor would like to offer a confidential (private) way for students to seek individual school counseling. It is important to keep in mind the following:

- If you are in crisis and have unsafe thoughts/actions (or concerned about a friend), please tell a trusted adult ASAP. **This form is only used for non-emergency uses.

- Your parent/guardian will be notified by Mrs. Statczar if you seek out school counseling so we can have their consent for ongoing meetings.

- Confidentiality: Mrs. Statczar has an ethical obligation to keep details disclosed by students in the counseling relationship confidential. However, if safety is a concern for you or someone else, Mrs. Statczar has an obligation to ensure safety for all.

Thank you for reaching out; we recognize it takes a lot of courage. You are never alone!

School counselor:
Jennie Statczar, M.A., LPCC 
Email: jstatczar1@cdeducation.org
Sign in to Google to save your progress. Learn more
Email *
First Name *
Last Name *
Grade/class (e.g., 7) *
I am… *
Required
Explanation *
Have you discussed your concerns with your parent or guardian? *
By typing my name, I understand this form is used for non-emergency mental health purposes and my parents/guardian may be notified if I seek out these services. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Spirit of Peace. Report Abuse
Google Forms