TMS Wellness Room Student Form
Hello! This is a form you can use to request a call from one of our Wellness Room Staff. We are here for you!

PLEASE NOTE:
This form is kept confidential/ private, unless there is a safety concern about you or someone else.

This form is checked on school days only BETWEEN 8am and 4pm.
We respond within 24 hours on School Days.

IF THIS IS A LIFE THREATENING EMERGENCY, CALL 911, OR CALL the Suicide Prevention Hotline 1-800-273-8255.

IF this is URGENT, You can also use the STOP-IT app

Thank you so much!
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What is the best number to reach you at? *
Student First Name *
Student ID # *
Grade *
Date *
MM
/
DD
/
YYYY
Why would you like the opportunity to go to the Wellness Room? *
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