Wellness Center Check-In Request
Complete the following information if you would like assistance from the La Mesa Wellness Center. You may access support from the Wellness Center during school days (Monday through Friday 8:30am-3pm). If this is an emergency, please contact a trusted adult or call 911 immediately./Complete la siguiente información si desea recibir asistencia del Centro de Bienestar. Puede acceder apoyo durante los días escolares (de lunes a viernes de 8:30am a 3pm). Si se trata de una emergencia, comuníquese con un adulto o el 911 de inmediato.  

If you know someone who needs immediate help, please call the National Suicide Prevention Lifeline at 800-273 TALK (8255) or contact the Crisis Text Line by texting HOME to 741741./Si conoce a alguien que necesita ayuda inmediata, llame a la Línea Nacional de Prevención del Suicidio al 800-273 TALK (8255) o comuníquese con la Línea de Texto de Crisis enviando un mensaje de texto con HOME al 741741.  

Sign in to Google to save your progress. Learn more
I hereby certify that I am 12 years of age or older, and I am the individual stated below consenting to seek out mental health support services from my La Mesa Junior High Howl Hut Wellness Center.
 *
First Name /  Primer Nombre *
Last Name /  Apellido *
Student ID Number /  Número de identificación del estudiante *
Grade / Grado *
Briefly describe how we can help. /  Describa brevemente cómo puedo ayudar. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of William S. Hart Union HSD. Report Abuse
Google Forms