PTHS Student Assistance Request -  CONFIDENTIAL
Please use the following form if you would like to speak to one of our Counselors or Child Study Team members.
Sign in to Google to save your progress. Learn more
Email *
Student name *
Telephone number
Grade *
What's on your mind ...... Please indicate the reason you are requesting to be contacted *
Best method of contact *
Required
Staff member to contact you (if you have a preference) *
Required
Name of individual completing survey *
Relationship to individual discussed in this request *
COMMENTS:
Other resources
Pequannock Township School District Information Regarding the Public Health Closure: https://sites.google.com/pequannock.org/ptsd-public-health-closure/home?authuser=0

In an immediate emergency call 9-1-1

PerformCare: 1-877-652-7624- If your or your child are currently experiencing a behavioral health crisis, please call immediately

NJHOPELINE: 855-654-6735- Confidential and anonymous hotline for counseling and support 24/7

2nd Floor: 888-222-2228 (can call or text), http://www.2ndfloor.org- Confidential and anonymous hotline to find solutions to problems you face at home, at school, or socially

National Suicide Prevention Hotline: 1-800-273-TALK (8255)- Confidential and anonymous hotline to discuss problems you are facing and feelings of suicide

 
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of pequannock.org. Report Abuse
Google Forms