Lee Early College Counselor Request Form
Thank you for reaching out to me.

This form has been updated!!!! Please read this entire message before proceeding.

** If you are experiencing an emergency, please talk to a trusted adult or call 911**
When school is open please notify Ms. Jackson or Ms. Derr directly or tell a Teacher asap.

*** If you aren't sure who you can talk to but are concerned that someone is being harmed, might harm themselves or might harm someone else you may also receive assistance by using the Say Something anonymous reporting app. The Say Something app can be downloaded to a cell phone through the App Store or Google Play. You can also access it using the link provided at the bottom of LEC's webpage. ***

Here are additional resources in case you or someone you know is experiencing a crisis:

National Suicide Prevention Lifeline: 1-800-273-8255 https://suicidepreventionlifeline.org/

Crisis Text Line: text HOME to 741-741 *The Crisis Counselor is a trained volunteer, not a professional. They can provide support, but not medical advice.*
https://www.crisistextline.org/purpose

THE FORM BELOW IS MAINLY DESIGNED TO COMMUNICATE NON-EMERGENCY CONCERNS TO THE SCHOOL COUNSELOR. All students may use this form to refer themselves to Ms. Jackson. Teachers, parents, and friends/peers may also use this form to refer a student to the school counselor.

Information from this form will be kept confidential unless I am mandated to report it by law or we agree that it is necessary to share in order to properly address the problem/situation.

Please be sure to provide a working e-mail address and telephone number because these are the main ways I will be able to communicate with you. Please check your email regularly for my response.

**Important Note**
** Responses to this form are checked periodically when school is OPEN.**
If school is closed (after school hours, weekends, holidays, summer, etc.), your submission may not be seen or addressed for several days or until school is open again. Urgent matters will be handled as soon as possible once I see it. Response times may vary under the current unusual circumstances. Routine concerns will be addressed as I am able to or after we return to school.

* If you are a student & this is an emergency, seek the help of a trusted adult right away *

Email address *
Untitled Title
My name is (please provide First and Last names)
Phone number (optional)
I am a...
Clear selection
If a student, my grade level is
Clear selection
The person or issue I am concerned about is (please provide First and Last name of the person if known.): *
The topic or issue is: (short answer e.g. grades, need to talk bullying, self-harm ...) *
My Concern is... (please provide a brief description so the counselor has some idea what is going on. ) *
This matter is *
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