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Student Request to Speak to the Counselor
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Best number to contact
Your answer
Full Name
*
Your answer
Grade
*
9
10
11
12
ID #
Your answer
Concern
*
Academic
Anxiety /Depression
Attendance
College counseling
Conflict Mediation
Death/Grieving
Family Issues
Health
Self-harm/Suicidal
Other:
Required
How Urgent?
*
Low (can talk this week)
Moderate (can talk within the next few days)
Critical (can talk until tomorrow)
Emergency (need to speak ASAP)
Your counselor will be in touch. If this is an emergency, please speak to a trusted adult ASAP, call 911, or one of these hotlines: (877)727-4747, (800) 273-8255.
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