SRCS School-Based Therapy Support: Request for Appointment

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Please use this form to request an appointment with a Santa Rosa City Schools school-based therapist. Appointments will be conducted either via Zoom (video conferencing) or by phone. Please note that these remote appointments are not intended to replace the student’s medical care or services provided by an outside mental health care provider. These services are intended to support students in identifying and managing difficult feelings, and in developing effective coping strategies during these challenging times.

IF YOU HAVE QUESTIONS ABOUT CLASSES OR ACADEMICS, PLEASE CONTACT YOUR SCHOOL COUNSELOR.

Last name: *

First name: *

Student ID (if available):

School: *

Please indicate some of the concerns you would like support around (mark all that apply): *

Feelings of sadness and depression

Feelings of fear, nervousness, or anxiety

Feeling isolated or lonely

Financial concerns (income, food, or housing scarcity)

Anxiety about grades or academics

Family problems

Help finding mental health support/other resources

Other:

Required

Are you currently receiving mental health services or have you received mental health services in the last 6 months? *

Yes

I don't know

If you answered yes to the previous question, please provide name and contact information for your mental health service provider (if available) and/or any other information that might be helpful for your school-based therapist to know:

A Santa Rosa City Schools school-based therapist will contact you to arrange for an appointment time. How would you like to be contacted? *

Text

Please provide your phone number and/or email address below so we can contact you to set up an appointment time: *

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