Counselor Check In

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Counselor Check In

Lizzie is available to chat on Google Meet with students or parents that request a time to check in through this form. In person sessions are also available while maintaining social distancing protocol. Please fill in the information below and Lizzie will be in touch to confirm a date and time. If this is something that is urgent, please exit this form and talk to a trusted adult that is close to you. If this is an emergency please call 911.

Email *

Date *

YYYY

First & Last Name *

Please select one *

8th grade

7th grade

Other:

How are things overall?

Not good

Excellent

Clear selection

How is school work going?

Not good

Excellent

Clear selection

How has your emotional/mental health been recently?

Not good

Excellent

Clear selection

Please rate how your overall wellness has been since the transition to distance learning in March of 2020?

Not good

Excellent

Clear selection

Primary area of concern

Academic

Social/Emotional

Behavioral

Resources

None

Other:

Clear selection

What do you need help with?

School Work

My choices

My future

My feelings

Friend Stuff

Family

None

Other:

Clear selection

Are you aware of people in your class engaging in self harm?

Yes

Clear selection

What would be the most helpful form of support for you and your classmates?

Weekly individual check in with Lizzie

Virtual "Girls Group"

Educating parents about self harm

Self harm crisis plan to address change

Educational meetings with Lizzie to talk about alternative coping strategies

Other:

Clear selection

How would you like to be contacted?

Google Meet/Zoom

Phone (provide phone number below)

I do NOT need a check in at this time. I will email you if anything changes.

Other:

Clear selection

Submit

Clear form

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