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Section 1 of 4
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Section 2 of 4
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Are you feeling overwhelmed and having trouble managing stress?
Are you having difficulty with a peer/classmate?
Are you having difficulty with a family member or someone outside of school?
Are you having difficulty with a teacher/administrator/school staff member?
Are you having feelings of sadness, loneliness or depression?
Are you having trouble focusing due to issues outside of your control?
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add "Other"
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Section 3 of 4
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Mr. Hancock, High School Counselor
Mrs. Masilionis, School Social Worker
Mrs. Burnett, School Psychologist
Mrs. Johnston, Elementary Principal
Mr. Hasenbank, Jr High Principal/AD
Mr. Johnson, Sr High Principal
Other…
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Section 4 of 4
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I need help right away
It can wait a couple of hours
it can wait one day
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add "Other"
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Before school
1st Hour
2nd Hour
3rd Hour
4th Hour
5th Hour
6th Hour
7th Hour
Seminar
After School
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Called to the office
Called to Mr. Hancock's room
Called to the Special Education Office (where Mrs. Masilionis and Mrs. Burnett work)
Called by telephone
Contacted via email
other
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What is your name and grade level?
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Concern(s)
What is the nature of your concern?
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Please briefly explain
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Identifying 'Help'
Please check all staff members below with whom you feel comfortable talking to.
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Meeting your need(s)
What type of problem is this?
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Best time to reach you (check all that apply)
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How would you want to be contacted?
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If "other" please explain below:
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What is the best phone number or email to contact you?
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