Mrs. Siwecki Appointment
Thank you for completing this form! Please allow 48-72 hours for your counselor to contact you. I am available Monday - Friday 8:00 am to 4:00 pm (except weekends, holidays, and academic breaks). 

If this is an EMERGENCY, meaning you are in danger of hurting yourself, hurting someone else or someone is hurting you, please speak to a trusted adult ASAP, call 911, or call/text 988 the Suicide and Crisis Lifeline. 
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I acknowledge that this form does not result in immediate crisis support. IMPORTANT: If this is a life threatening emergency, and you or someone you know requires immediate assistance, please call 911 or go to your nearest hospital emergency room.  *
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I am the: *
Student Last Name, Student First Name *
Student ID # *
Grade: *
What would you like to discuss? (Check all that apply)
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What is the significance of your concern?
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I just have questions/concerns. Please contact me at your convenience.
I am not okay. I need immediate assistance. Please contact me right away!
What is the best way to reach you? *
When is the best time to reach out? (if requesting phone or in person contact)
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Please provide a brief description of your concern 
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