Counseling Request Form
The School District of DeSoto County is offering virtual counseling opportunities for students during school closures. To request that a Social Worker/Mental Health Counselor contact you to discuss counseling for your child, please complete the form below. This form is for NON-EMERGENCY USE ONLY.

Please note: If you are requesting services for multiple children, a separate form must be completed for each child.
Email address *
Your name: *
Your answer
Child's Name: *
Your answer
What is your relationship to the child: *
If "Other" was selected to the question above, please provide more information about your relationship to the child.
Your answer
Please select your child's school:
Child's Date of Birth (mm/dd/yy) *
Your answer
Is the child currently receiving counseling services? *
If you answered yes to the above question, please specify the provider below.
Your answer
Contact information: Please provide one or more contact numbers below. *
Your answer
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