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!
* Required
What is the best number to reach you at?
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Your answer
Student First Name
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Your answer
Student ID #
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Your answer
Grade
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Your answer
Date
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MM
/
DD
/
YYYY
Why would you like the opportunity to go to the Wellness Room?
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Because I am feeling anxious or stressed
Because I am really struggling with life right now
Because I am having a hard time in my classes
Because I am in a really dark place right now
Because I am having trouble at home
Other:
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