Request for Mental Health Counseling

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Email *

Last Name *

First Name *

Marina High Student ID # *

Grade *

9th

10th

11th

12th

I would like to receive support because I am feeling *

Sad

Anxious

Tired

Stressed

Depressed

Overwhelmed

Nervous

Mad

Irritable

Academics

Other:

Required

Due to COVID 19 do you need information/assistance on any of the following? *

Food

Rent Assistance Information

Medical Information

Internet

Mental Health Referral

Transportaion

None of Above

Other

Required

Please Indicate how you would like to be contacted. Provide your email and/or phone number. *

Thank you. A MaHS representative will be in contact soon. If this is a mental health emergency, please call 911. If you need to reach out to support prior to our response, please utilize the crisis lines available: Call 1-800-273-8255 or Text: Connect to 741741 *

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