Requesting Counseling/Social Work Check-In

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Please use this form if you have concerns about your own health or safety, or the health or safety of another student.

In case of an emergency, do NOT wait for a response. Contact 911 immediately. If you are experiencing a mental health related emergency, call 988. Response from WAVE staff may take between 24-72 hours. All information is confidential.

Student's name that you are concerned about (yourself or someone else). *

Name of the person completing this form (if not comfortable sharing, put anonymous) *

A description of your concern (please include all relevant information). *

Best way to contact you (phone number, email address)

Best way for us to contact the person you are concerned about (phone number, email address) *

Are you a staff member, or a student? *

Student

Staff member

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