Family Request for Counselor Contact Form
Thank you for reaching out! The information on this form will be sent to the Jefferson Counseling Department. 
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Student First Name *
Student Last Name *
Student Grade *
Person completing the form *
Relationship to student *
Best way to contact you (please include the contact information) *
Counselor you would like to speak to:
Reason you are reaching out and support needed? *
Required
On a scale of 1 to 10, please rate your level of concern. *
Lowest Concern
Highest Concern
 If you or a family member is experiencing a mental health crisis (threats of harm to self or others), please call 911. If you or a family member is experiencing any kind of emotional crisis, mental health or substance use concern, you can find help 24 hours a day, seven days a week, by calling the New Mexico Crisis and Access Line at ​1-855-NMCRISIS (1-855-662-7474) or ​Peer to Peer Warmline ​at 1-855-4NM-7100 (1-855-466-7100). nmcrisisline.com *
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