Counseling Service Request

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This form is to be used to speak with a counselor about something that you or someone you know may be struggling/dealing with. This is a confidential form that will go to our Adams Central counseling team. There are instances, however that are required by law to be reported to additional authorities.

Requests may not be checked on weekends. If this is a life threatening emergency please contact 911 or the Suicide Hotline at 1-800-273-TALK (8255) or text LOOKUP to 494949.

Your First and Last Name

If you not a current student, please provide a phone number or valid email address

Is this form about you or someone else?

Someone else

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