Counseling Information Request Form

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If you are interested in obtaining additional information about school-based counseling support for your child, please complete the information below.

Email *

Parent/Guardian FIRST and LAST NAME: *

Parent/Guardian phone number: *

Student FIRST NAME: *

Student LAST NAME: *

School-based counseling is provided by the school counselor, district social worker, mental health intern, or school psychology intern. Counseling is typically short-term (6-weeks) but in certain situations can extend for a longer period of time. Please make your selection: *

I am interested in school-based counseling.

I am still unsure but would like additional information about school-based counseling.

Please describe why you are interested in school-based counseling support for your child (be as detailed as possible in describing your child's situation): *

Would you like the counselor to check-in with your child at school as soon as possible? *

Yes, please do a brief check-in with my child at school.

No, please do not check-in with my child at school at this time.

Please indicate any supports your child has received (currently or in the past): *

School-based counseling

Counseling at an outside agency

None

What is your preferred method of contact (select all that apply): *

Phone

Text

Required

Thank you so much! I will review your request and reach out to you.

Mrs. Dysim, School Counselor

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