Counseling Request Form

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Fill out this form as completely as you can. Once you submit the form, a counselor will be in touch with you as soon as possible!

If you need immediate medical assistance, please call 911.

National Suicide Prevention Hotline
1-800-273-8255

(Spanish) National Suicide Prevention Hotline
888-624-9454

Crisis Text Line
Text ‘HOME’ to 741-741

Student Last Name *

Student First Name *

Student ID *

Student Phone Number *

Student Email Address (either school email or personal) *

Student Grade Level *

Reason/s for needing to see your counselor *

Academic needs (grades, schedule changes, AP/Dual Credit)

Mental health needs

College/career needs

Grief/loss

Other:

Required

If you need college/career help, do you need to speak with Mrs. Carnes?

Yes

Maybe

Other:

Clear selection

Rate your situation on a scale of 1 to 5, with 1 being a non-emergency and 5 being a big emergency. *

Not an emergency - I just need to talk

Huge emergency - I might need medical attention

Briefly describe what you are seeking to accomplish by speaking with your counselor. *

Submit

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