Student/Family Request For Assistance Form
Please remember:

If you have an immediate concern, such as a student with suicidal ideation or self-harm, during the student school day, contact a counselor or administrator immediately. PLEASE keep the student with you until you have connected the student with a Counselor or Administrator.

If you need emergency assistance, dial 911, 1-800-273-8255 (National Crisis Line), or go to the nearest Emergency Room.

Please allow 24-48 business hours for counselor to respond.
Email address *
Your Name (name will be anonymous): *
Your answer
Student's Name (concerned about): *
Your answer
If more information is needed, contact me at:
Your answer
Your relationship to this student:
Your answer
Grade Level (if known):
Student ID # (if known):
Your answer
Reason(s) for referral: *
Your answer
Other important information that we should know about this student:
Your answer
A copy of your responses will be emailed to the address you provided.
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