Mental Health Supports: Self-Referral

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Life gets hard... Sometimes we need a little support. You are NOT alone. If you are interested in getting some support, complete this form and let us know what kind of support you are looking for! A JHS school social worker or counselor will be in touch with you soon!

If this is an URGENT situation, call 911 or Crisis at 651-266-7878.

Email *

First and last name and CIF: *

I am interested in the following support: *

School Based Therapist: Ms. Aysa (HealthStart Clinic)

In-School Therapist: Ms. Nikki (LifeStance)

I want to talk to a School Social Worker.

I want to talk to my School Counselor.

I am interested in joining a confidential support group with other students that go to Johnson.

I am not sure what I want or need but would like to talk to SOMEONE!

What I need support with is: *

I am currently connected to the following supportive people at Johnson: (if no one, state "nobody" or N/A) *

I prefer to talk to: *

a female

a male

It doesn't matter: I just want to talk to someone.

How do you want us to connect with you? (email, text, in-person conversation) *

Send me a copy of my responses.

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