Request for Counseling Services
Parents or students may fill out this form to request counseling services
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Email address *
Telehealth Counseling Service Agreement
Please be advised that by allowing your child to virtually meet with the school counselor, you are also agreeing to having an adult present in the home while the child and counselor are speaking in a separate room. The Archdiocesan Policy indicates that in case of emergency, a parent/guardian will be immediately available.
Please read the consent forms linked below
Telehealth Consent Form

https://drive.google.com/file/d/1jKw7_2JJXX6qwzqBiXS0PAF5Rc1ekv1q/view?usp=sharing

Parent Consent Form

https://drive.google.com/file/d/1eJXb3PU_q4ZVAMH-PBX1b3-NSgpYk_iP/view?usp=sharing

Do you consent to the forms above? *
Who is requesting the service? *
Date *
年
/
月
/
日
Student Name
Grade *
Please indicate the size of the problem *
What do you need help with? *
How would you like for me to contact the student? *
必填
Please provide a parent phone number *
Office hours are Monday - Friday from 8 am to 3:30 pm. If virtual meetings are preferable, please provide at least 2 different days/times that work best for you. *
Please provide any extra information that you would like for me to know *
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