Counselor Check-In Request
Please complete this form if you have a concern about a student and would like Ms. Brittany to check in with them

Below are resources available should you find yourself or someone else in a situation where immediate mental health services are needed.

National Suicide Prevention Lifeline --- 988
Crisis Hotline for Youth & Families --- 1.800.999.9999
Stanislaus County Behavioral Health & Recovery Services --- 1.888.376.6246
Foster Care Family Urgent Response System -- 1.833.939.3877
Domestic Violence -- 1.800.799.7233
* Indicates required question
Email *
Are you a Parent/Guardian or Student?  *
Your First Name *
Your answer
Your Last Name *
Your answer
Phone Number *
Your answer
School *
Grade of student: *
Reason for Check in Request
*Academic: (school performance, not engaged, lacks motivation, easily frustrated, easily distracted, etc.)
*Social-Emotional: (anxious, aggressive, withdrawn, poor social skills, poor emotional regulation, etc.)
*Personal and/or Home Environment: (death in family, addition to family, separation, major life transitions, etc.)
Briefly state your concern. *
Your answer
Goals
Based on your concern(s), list one goal you have for you/your student?
Your answer
Additional Comments
Please include services currently offered to you/your student.
Your answer
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