Want to speak to your school counselor? Fill out this form.

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Please fill out the following check-in. I would love to hear from you! Your responses will be sent to Mrs. Amber & Mr. Tom to follow up with your preferred method you requested for me to call you within 24 hours.

**Important Information**
This form is for non-emergencies only. If it is an emergency (thoughts of harming yourself or others), do NOT contact your school counselor. Instead you can call the following numbers for help:

Call 911
Crisis Text Line: "HELLO" to 741741
Call the National Suicide Prevention Line: 1-800-273-8255
Trevor Project Lifeline (Available 24/7; Confidential Suicide Hotline for LGBT Youth): 866-488-7386

Please understand that confidentiality cannot be guaranteed via phone conferences. I will make every effort to ensure a confidential conversation but I will notify appropriate individuals if any of the following come up in our conversation:
1. Someone is hurting you.
2. You want to hurt someone.
3. You want to hurt yourself.
4. You give us permission to share with another trusting adult.

First and Last Name *

What grade are you in?: *

Kinder

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

Why would you like a check in? (You can choose more than one.) *

I am feeling sad, worried, stressed, angry, or just not myself and can't focus in class

I have a BIG problem (I am getting hurt or I feel unsafe) that I need to report to an safe adult

I've tried to solve my SMALL problem on my own two times and I need advice

Other:

Required

Have you talked to your parents or guardians about this? *

Yes

Do you have anything to tell me? This can be about school or life.
*

What do you need so that things are better for you? *

Submit

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