SRCS School-Based Therapy Support: Request for Appointment
Please use this form to request an appointment with a Santa Rosa City Schools school-based therapist. Appointments will be conducted either via Zoom (video conferencing) or by phone. Please note that these remote appointments are not intended to replace the student’s medical care or services provided by an outside mental health care provider. These services are intended to support students in identifying and managing difficult feelings, and in developing effective coping strategies during these challenging times.
IF YOU HAVE QUESTIONS ABOUT CLASSES OR ACADEMICS, PLEASE CONTACT YOUR SCHOOL COUNSELOR.
Sign in to Google
to save your progress.
Student ID (if available):
Elsie Allen High School
Maria Carrillo High School
Montgomery High School
Piner High School
Ridgway High School
Santa Rosa High School
Herbert Slater Middle School
Hilliard Comstock Middle School
Lawrence Cook Middle School
Rincon Valley Middle School
Santa Rosa Middle School
Abraham Lincoln Elementary
Albert Biella Elementary
Brook Hill Elementary
Helen Lehman Elementary
Hidden Valley Elementary
James Monroe Elementary
Luther Burbank Elementary
Proctor Terrace Elementary
Steele Lane Elementary
Cesar Chavez Language Academy
Santa Rosa Accelerated Charter
Santa Rosa Charter School for the Arts
Santa Rosa French-American Charter
Please indicate some of the concerns you would like support around (mark all that apply):
Feelings of sadness and depression
Feelings of fear, nervousness, or anxiety
Feeling isolated or lonely
Financial concerns (income, food, or housing scarcity)
Anxiety about grades or academics
Help finding mental health support/other resources
Are you currently receiving mental health services or have you received mental health services in the last 6 months?
I don't know
If you answered yes to the previous question, please provide name and contact information for your mental health service provider (if available) and/or any other information that might be helpful for your school-based therapist to know:
A Santa Rosa City Schools school-based therapist will contact you to arrange for an appointment time. How would you like to be contacted?
Please provide your phone number and/or email address below so we can contact you to set up an appointment time:
Never submit passwords through Google Forms.
This form was created inside of Santa Rosa City Schools.