SYMS Counseling Referral Form

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Please fill out this form if you (or someone) would like to talk to a counselor.
Complete este formulario si usted (o alguien) desea hablar con una consejera.

***If you are having a mental health or life-threatening emergency, call 911 or go to the nearest hospital.

Si tiene una emergencia, llame al 911 o vaya al hospital más cercano.***

If you are not able to talk to a trusted adult, call the Crisis and Access Hotline at (888) 724-7240.

Si no puede esperar para que responda un consejero, hable con un adulto de confianza, o llame al 1-888-628-9454 a la linea directa para personas en crisis.

Thank you,

Gracias,

Mrs. Wilhelm

Student First and Last name (nombre y apellido): *

Student Grade (grado): *

7th

8th

I am a (soy): *

Student (estudiante)

Parent/Guardian of a student (Padre/Guardián de un Estudiante)

Staff

Reason for counseling (motivo para hablar con consejero/a): *

Friendships, relationships (amistades)

Grades (grados/calificaciones)

Home (algo de familia o del hogar)

Something else (algo diferente)

Please rate how you are feeling about the problem (califique el nivel del problema). *

Minor (no muy urgente)

Emergency (Tú o alguien más están en peligro)

Additional information (información adicional):

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