High School Student Support Request Form

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We want you to know that the student support staff at Homer Community Schools is available to help students and parents.

If you would like to speak with someone confidentially about concerns that you have for your physical, emotional, or mental health needs, please complete the following form and someone will follow up with you.

If you are concerned about a student and would like someone to follow up with them, either for physical, emotional, or mental health needs, please complete the following form.

If you are not sure who to talk to, you can fill out this form and someone will contact you within 48 hours.

IF THIS IS AN EMERGENCY, PLEASE DO NOT FILL OUT THIS FORM!!!
CALL 911 or CONTACT A MEDICAL HEALTH PROFESSIONAL IMMEDIATELY!!!

Parents/Students: Anything shared with a member of the Student Support Team will be kept confidential unless a student discloses an intent to harm himself/herself or someone else.

Staff: All staff are mandatory reporters and any information shared with you that falls under these guidelines must be reported immediately.

Student - First and Last *

Grade of Student Listed Above *

Freshman - 9th

Sophomore - 10th

Junior - 11th

Senior - 12th

Required

Is the Student In Person or Fully Virtual? *

In Person

Fully Virtual

Please write a detailed description of the question, concern, or issue that you would like to talk to someone about. *

If you are not physically in the school building, how would you like to be contacted?

Phone

Zoom/Google Hangout Online Chat

Other:

Clear selection

Is there a specific person that you would like to contact you? (We cannot guarantee that this specific individual will contact you within 48 hours, but SOMEONE will.

Mrs. Gwenda Kelly, HHS Guidance Counselor

Mrs. Tammie Calhoun, K-12 School Nurse

Mrs. Wendy Danko, K-12 Social Worker

Mrs. Bridget Young, K-12 Mental Health Specialist

Person Submitting Request Form *

Student - Self Submitted

Teacher/School Staff

Another Student

Parent

Other:

Optional: Name of Person Submitting Request (required if a teacher/school staff)

Submit

Clear form

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