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Virtual Contact Counseling Request - Student
Please complete form for virtual counseling request. I will contact via email or phone. Please use your school email address. Looking forward to connecting with you!
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Email
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Your email
Option 1
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Student First & Last Name:
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Your answer
Name of School:
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BIS
CAHPS
CRA
Headwaters
Other:
Today's Date:
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Your answer
Perceived urgency of need: (If you are feeling unsafe to yourself or suicidal - please call 911 or call the suicide hotline (800)273.8255 - please reach out to an adult for immediate help.
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1. Urgent (imminent danger to self or others or experiencing abuse/neglect at home.)
2. As Soon As Possible (loss, depression, anxiety, needs clothing, food)
3. When Convenient (non-emergency)
4. Career/College/Scheduling
What is the best time to call you morning or afternoon?
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Your answer
What is your phone number?
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Your answer
Concern/problem:
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Your answer
Virtual/Distance School Counseling Confidentiality- by checking the box you understand confidentiality in school counseling and limitations of confidentiality. Confidentiality is of the utmost importance between student and school counselor and is maintained at all times with the following exceptions: (1) Report of harm to self or others (2) Abuse or neglect (3) Court, other legal proceedings.
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Yes, I understand the confidentiality guidelines.
No, I do not understand the confidentiality guidelines.
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