Student Wellness Services Request for Help
If you are experiencing a crisis or an emergency, dial 911, or go to your local emergency room.
For non-emergencies, please fill out this request form for assistance. We will process this request as soon as possible. Thank you!
Email address *
The Student Wellness Services Request for Help will be processed in the order that requests are received. This may not be the same day. If this is an emergency please dial 911 or go to your local emergency room for immediate assistance. *
Campus Name *
Please enter the student's campus. If unknown, please select the Unknown option.
Student's Grade *
Please select the student's grade. If unknown, please type Unknown.
ID Number *
Please enter the Student's ID number. If unknown, please type Unknown.
Last Name *
Please enter the Student's Last Name
First Name *
Please enter the Student's First Name
Assistance Needed: *
Additional Comments *
In order to best assist you, please provide specific referral information, explain what help is being requested.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Goose Creek CISD. Report Abuse