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EOPA Mental Health Counseling Request Form 2021-2022
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)
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Email *
Full Name *
Student ID #
Grade *
Student Cell Phone # *
Who are you looking for support for? *
If you are referring another student, what is their name?  
Please share the reason you are seeking support:
Please mark all that apply
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