Self Referral Form
Students and Parents can use this to refer themselves or their child to the appropriate counselor. Once completed this referral will send an email to Ms. Leach, who will then forward it to the appropriate counselor. Teachers, please find the counselor form specifically for staff located on the For Teachers & Staff page on Dohn's website.

Please note: Counselors do not maintain 24/7 access to their emails.  Your safety & well-being are important to me!
If this is a counseling emergency, please reach out to one of these resources:
Suicide Hotline: 1-800-273-8255
Talbert House Crisis Line (Hamilton County): Call 513-281-2273 or text Talbert to 839863
Crisis Text Line: text "HELLO," "START," or "HOME" to 741741
Safe Schools Tip Line: Call or text 1-844-723-3764
Sign in to Google to save your progress. Learn more
Email *
What is today's date? *
Guardian's Name (if applicable):
Student's Name: *
Student's Campus: *
Who is referring the student? *
What is a working number for the student? *
If you are a guardian, what is a working number for yourself so we can contact you if needed?
For students ONLY: What day usually works best for you to meet with staff? (Check any day that applies) *
Is this an emergency (aka safety concern)? *
Is this for transcripts, credits, or Bubble Sheets? *
What is the concern? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dohn Community High School. Report Abuse