Counseling Appointment Request

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*If this is an emergency (you or someone else is in danger) and you are filling out this form outside of school hours, please contact law enforcement or tell a trusted adult who can help.

First Name *

Last Name *

What team are you on *

Person you are requesting to speak with *

6 - Mrs. Mitchell

7 - Mrs. Cruz

8- Mrs. Fincher

Mrs. Bull - Groups

Mrs. McNulty - Groups

Luna - I do not need to see a counselor, but would like to see Luna when she is available. **This means that your counselor will send for you during electives or advisement when Luna is not busy. Please note that this may take some time.**

Reason for request *

Concern for my own, or someone else's safety (please check 4 or 5) - WAIT HERE FOR THE NEXT AVAIL. COUNSELOR

Friend issues

Academic

Home/family issues

I need to make an incident report - (Please ask a staff member to fill out this report out before returning to class)

Stress or Anxiety - if so please rate your anxiety level below (1-low to 5-high)

Other:

Other Reason for request - please explain if needed - or provide additional details for request here

Rate your stress / anxiety level

Low

High

Clear selection

Please mark the appropriate number on the scale. If you mark 5 (very urgent), please wait for the next available counselor. *

Not an emergency

Very Urgent (safety concern)

Submit

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This form was created inside of DCSD.