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2025/26 Student Self Request For Wellness Support
Please fill out all answer fields and be sure to press "Submit." The Wellness Center staff will be in contact with you within 1 week.
*IF YOU ARE HAVING ANY THOUGHTS OF SUICIDE PLEASE COME TO THE WELLNESS CENTER IMMEDIATELY OR CONTACT THE SUICIDE HOTLINE @ 988 or text 988
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Email *
School *
Student Name *
Student ID # *
Who is your school counselor?
Grade *
Your Gender Identity *
Check all of the items you would like to talk with someone in the Wellness Center about (check all that apply): *
Required
Are your parents aware you are wanting to talk to someone in Wellness: *
If you are signing up for an upcoming group, what is the group topic?
What is your phone number that we can call you at?
What is your email that we can contact you at?
What period is good for us to set up an appointment for you ?
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Mandatory Acknowledgement *
I acknowledge
By checking this box you understand that parents/guardians will be notified that a request for support through the Wellness Center has been submitted. The information shared in this form will remain confidential. If services are initiated through the Wellness Center (i.e. therapy, groups, etc...) we will need a consent form on file signed by a parent/guardian for those services. If you have any further questions please stop by the Wellness Center before or after school.
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