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Hart Wellness Center Appointment Request
If you would like to be contacted by someone, for mental health support for yourself or to discuss support for a friend, please fill out this brief questionnaire. It will be used to best meet your needs.
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* Indicates required question
DISCLAIMER: This form is only to be used for mental health support.
If you are trying to contact a counselor for any other reason, click here
https://tinyurl.com/Hart-Counselors
What is your FIRST name?
*
Your answer
What is your LAST name?
*
Your answer
Grade
*
9
10
11
12
What is the best phone number to reach you? (Please include your area code)
*
Your answer
How urgently do you need to be contacted?
*
Need support ASAP
I'm ok. But the sooner the better.
It can wait, nothing urgent
Briefly describe how we can help:
Your answer
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