Mrs. Young Appointment

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Thank you for completing this form! Please allow 48-72 hours for your counselor to contact you. I am available Monday - Friday 8:00 am to 4:00 pm (except weekends, holidays, and academic breaks).

If this is an EMERGENCY, meaning you are in danger of hurting yourself, hurting someone else or someone is hurting you, please speak to a trusted adult ASAP, call 911, or call/text 988 the Suicide and Crisis Lifeline. 

I acknowledge that this form does not result in immediate crisis support. IMPORTANT: If this is a life threatening emergency, and you or someone you know requires immediate assistance, please call 911 or go to your nearest hospital emergency room.
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I Agree

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Last Name, First Name. *

Grade *

You are a ... *

What would you like to discuss? (Check all that apply) *

Academic (Study Skills, Test Taking, Time Management etc)

Personal/Social Emotional (Conflict with Friends, Family Concerns, Feeling Sad, etc)

College and Career (High School Planning, College Planning, Career planning, etc )

Student Concern (Concern about another student)

Scheduling Concerns

Other

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What is the significance of your concern? *

I just have questions/concerns. Please contact me at your convenience.

I am not okay. I need immediate assistance. Please contact me right away!

Best way to reach you? *

When is the best time to reach out? (if requesting phone or in person contact) *

Please provide a brief description of your concern *

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