MSN Social-Emotional Support Request Form

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Please complete the questions below in order to request support from a staff member.

NOTE: If you feel you (or your student) are in IMMEDIATE danger, please utilize emergency services (reporting to your nearest emergency room, dialing 911, contacting an adult in your home right away). Do NOT use this form in an emergency situation.

STUDENT Name (First Name, Last Name) *

I am a (select one) *

Student

Parent

I (or my student) need to talk to someone (select one) *

Sometime in the next 1-2 days

Sometime this week (NOTE: If this form is completed on a Friday, a staff member may not reach out until Monday)

I (or my student) would like to talk to (select one) *

A specific staff member

Whichever counselor, social worker, or psychologist is available

Other:

If you (or your student) would like to speak to a specific staff member, please list the staff member's name below.

I (or my student) would like to talk about the following concerns (check all that apply) *

Problem with a peer/friend

Problem at home

Feelings of stress, anxiety, or depression

Concern about a friend

Other:

Required

Additional Notes (please feel free to leave any additional information that might be helpful for the staff member responding to know)

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