VSSA Counseling Support Referral Form
COUNSELING REQUEST FORM: Please fill out the form below to request a meeting. Allow 1-7 days for them to get you. If this is something that is time sensitive please rate your issue/concern as a 5 at the bottom.

Counselors DO NOT respond to meeting request forms outside of school hours.
If this is an emergency, please call 911 or the Hope Center Crisis Line at (970) 306-4673.
 
Call Safe-To-Tell to anonymously report any safety concerns:: https://safe2tell.org/ 

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Email *
Name of person completing this form:
Relationship to student of concern
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Student's First Name
Student's Last Name
Grade
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Who would you like to see
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Are you or anybody else in danger in someway? *(harm to self or others)
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IF YES TO ABOVE QUESTION PLEASE TELL ME MORE....
I need to talk with you about: * *
Required
Other comments or information about what is occurring
Please rate the issue or concern on a 1 – 5 scale.                                                                            1 = Something is wrong and would like to talk to talk to someone this week.                                                                                                                                                                       5 = I need to talk to you as soon as possible. *
***Counselors DO NOT respond to meeting request forms outside of school hours.*** If this is an emergency, please call 911 or Hope Center Crisis Line at (970) 306-4673. Call Safe-To-Tell to anonymously report any safety concerns:: https://safe2tell.org/ 
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