EOPA Mental Health Counseling Request Form 2021-2022

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Your referral matters. If this is an urgent situation such as suicidal thoughts or concerns about the safety of others, please call 9-1-1 or speak directly with a responsible adult (i.e. school staff or family member)

Email *

Full Name *

Student ID #

Grade *

Student Cell Phone # *

Who are you looking for support for? *

Myself

Another student at the school

If you are referring another student, what is their name?

Please share the reason you are seeking support:

Please mark all that apply

Sad, depressed or irritable mood

Withdrawn/isolates self

Problems with friends or other students

Problems with family

A recent loss (e.g. break up) or death

Angers easily

Aggressive behavior

Bullying (Target/Aggressor)

Challenges with teachers and other adults in school

Challenges with drugs and/or alcohol

Involvement with law enforcement such as citations, probation or previous incarceration

Dating/partner issue

Need information about sexual health

Gender/sexual identity

Housing and/or homelessness issues

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