Non-Emergency Student Support Request

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Please complete this form if you are seeking non-emergency, non-urgent support for yourself or for your student.

FOR CRISIS OR EMERGENCIES:
* If you are experiencing a medical or psychiatric EMERGENCY, please call 9-1-1 or go to your nearest hospital.
** If you are concerned that you or someone else is an IMMEDIATE DANGER to themselves or another person, please call 9-1-1 or contact your local law enforcement. You can also request that a Crisis Intervention Trained (C.I.T.) officer do a welfare check for concerns regarding the safety of others.
*** If you need IMMEDIATE support, please contact one of the crisis resources provided below:

CRISIS LINES AND WEBSITES
- Lifeline Crisis Chat: crisischat.org

SUICIDE PREVENTION HOTLINES
- National Suicide Prevention Hotline: 1.800.273.8255

MOBILE CRISIS UNITS
- See MCC's Student Document and Links Page.

Are you a student making a referral for yourself or are you a parent/guardian making a referral for your student? *

I am a student and am making a referral for myself

I am a parent/guardian and am making a referral for my student

Student's Name *

What challenges are you/your student facing? (Select all that pertain) *

Academic (grades, workload - too much, not enough; stress, college applications etc.)

Sadness, anxiety, depression, or other mental health challenges

Personal relationships or family issues

Housing, food, and/or financial insecurity

Concerns or fears about the future

Physical health issues or concerns

Internet or technical challenges

Other:

Required

What supports might help you/your student? (Select all that pertain) *

Individual check in with a guidance counselor or mental health coordinator.

Support with college and career applications and/or financial aid.

Group meetings with peers to discuss shared/similar challenges.

Study groups or academic-support groups with peers.

Help getting developmentally appropriate assignments.

A quiet place to do school work.

Support with establishing a daily schedule/daily routine.

Individual check in with the school Health Office.

Referral to a community organization for issues like food, housing, employment, etc.

Other:

Required

Any other information we should know?

Best contact information for you? *

Best time to contact you? *

Morning

Afternoon

Evening

Other:

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