Arcade Counseling and Support Request

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* Answers to this form are CONFIDENTIAL and go directly to the counselors at Arcade Middle School *

Email *

We are here to support you! Please fill out this form if you would like to speak with a counselor or school social worker. If you prefer, there are also Counseling Self-Referral forms at the end of the A hallway. Fill one out, stick it in the Counseling Locker, and we'll get back to you.

**** If it is AFTER school hours and you are having thoughts of suicide, please call or text 988 to reach the Suicide Prevention Lifeline, or text HOME to 741741 ****

Once you've received help, please fill out this form for yourself or your friend so we may follow up with you.

Today's date: *

YYYY

I need help for (check one) * *

Myself (me)

A friend

Name of person who needs support (first and last): *

If this request is for a friend, please provide YOUR name here. It will be kept confidential. If this request is for you, please write "me". *

Something to remember...

After reading the picture above, do you understand there are limits to confidentiality, such as if you are planning to hurt yourself or someone else, or if someone else is hurting you? *

Yes, I understand

No, I do not understand

I need help with, or my friend needs help with... (Check all that apply): *

Feeling sad or hopeless

Feeling lonely

Feeling angry or mad a lot

Feeling worried or anxious

Resolving a conflict with another student

A bully or cyber-bully at Arcade

Racist or Xenophobic act or remark made by another Arcade student

Problem at home

Someone touching me in a way that I don't like

I want to hurt myself

Not feeling safe

Someone hurting me

Eating too much or too little

Struggling with drugs/alcohol

LGBTQIA+ question or concern

Unstable housing (facing homelessness)

Other:

Required

Would you like a counselor or school social worker to reach out to you this week? *

Yes

Does your parent or guardian know what is going on? *

Yes, for sure.

No way.

They might, but I don't feel comfortable talking to them.

Other:

If other, please explain:

Is there anything else you would like us to know?

If this is NOT an emergency, do you have a preference for who you want to speak with? We cannot guarantee this person will be the one to respond, but we know sometimes you have preferences :) *

Ms. Andrea, school counselor

Mr. Derum, school counselor

Ms. Lillian, school social worker

Mr. Lonnie, school social worker

Doesn't matter/No preference

Remember, we are available only during school hours, Monday-Friday. *** WE WILL NOT SEE URGENT MESSAGES OVER THE WEEKEND OR ON HOLIDAYS. PLEASE CALL/TEXT CRISIS LINE, IF NEEDED (see top of form)***

Thank you for sharing. If requested, one of the counselors or school social workers will reach out to you soon.

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