G.R.O.W.L Wellness Center Request and Referral for Support

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Thank you for reaching out! To request support for yourself or for a student that you feel would benefit from a Wellness Counselor checking-in, please complete this form. When we receive your request, we will send out a summons. We will try to get you in the same period that the request was received, but will do our best to respond as soon as we can. We are here to help!

If you are the student completing this form, I hereby certify that I am 12 years of age or older and I am the individual stated above to seek out mental health support services from Golden Valley High School at my school wellness center.

Request/Referral Made By: *

Myself (student)

Teacher/Staff

Parent/Guardian

Student's Full Name *

Student ID# *

Reason for Request *

Feeling anxious, sad, angry, or other emotion, and need a safe space. May need to talk.

Need a break or quiet place to refocus or regroup. Doesn't want to talk to anyone.

Other

Is there any additional information you would like to share with the Wellness team that would help us provide necessary support?

What period would the student prefer to be called out of if we can accommodate? *

We are here to help. Thanks for reaching out. Someone will assist you as soon as they are available.

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