Drug & Alcohol Intervention Individual Counseling Request Form

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Please complete form to request a counseling session with the Drug & Alcohol Prevention/Intervention Counselor- Mrs. Wright
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Feel Free to contact me at Umeka.Wright@gpisd.org

CONFIDENTIALITY DISCLOSURE: Information shared on this form is seen by the Drug & Alcohol Prevention/Intervention Counselor and and will not be shared with anyone UNLESS you disclose safety concerns (such as you wanting to hurt yourself, someone is hurting you or you want to hurt others).

电子邮件地址 *

Counselor you are requesting to see

Ms. Lewis

Mrs. Wright

清除所选内容

Student Name *

Student ID Number *

Parent Name *

Phone number

Individual completing form *

Parent

Student

其他:

必填

MOOD CHECK!

How are you doing? - Using the chart above select your mood below. *

Level 1 -The Struggle is Real (I need a counseling session)

Level 2- I'm just "OKAY"

Level 3- "It's ALL GOOD

I am fine, but would like to talk with you

其他:

必填

Would you like for our Drug & Alcohol Prevention/Intervention Counselor to contact you?

How would you like to be contacted?

提交

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