This form is for students who have already been referred by a parent/guardian to receive School-Based Therapy services through Jodi Province Counseling.

Please complete this form if you would like to request an appointment with Dr. Coleman through Jodi Province Counseling Services at Central Wilkes Middle School.  Please do not submit personal/private or confidential information in this form.  I am typically at CWMS on Mondays, Tuesdays, or Thursday afternoons.  I will do my best to call you for your appointment the same week you put in your request.

Your confidentiality as a student is important to me! In our counseling sessions, what is said here, stays here, with the following exceptions: as required by law and/or ethical standards; harm to self or others, abuse or neglect, and/or court or other legal proceedings. If there is ever a need to reveal information, I will let you know in advance, and work with you to handle the situation in a way that respects you, your feelings, and your needs.

This form is should not be used for emergencies.  In case of a mental health emergency, contact Daymark Mobile Crisis at 866-275-9552, the National Suicide Prevention Lifeline at 800-273-825 or call 911.