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Social Work Appointment Request Form
DISCLAIMER: Due to the limitations of remote engagement, all emergencies and crisis calls should be directed to your local police department or call 911.
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* Indicates required question
Email
*
Your email
Last Name
*
Your answer
First Name
*
Your answer
Student ID Number
*
Your answer
I would like to discuss (Check a response).
*
Bullying/Harassment
Academic Issue
Disagreement with teacher or family
Relationship Issue/Break-up
Fight
Suicidal Concerns (self or others)
Major Depression
Panic/Anxiety
Destructive/Negative Thoughts
Safety concerns (self or others)
Self-harm thoughts or actions
Required
On a scale of 1 - 10, how would you rate your level of emotion?
*
Little distress (very little) - I can manage for a few days.
1
2
3
4
5
6
7
8
9
10
Extreme distress (worst possible) - I need to talk now!
A copy of your responses will be emailed to the address you provided.
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