Wellness 2020-21 Referral Form
Thanks for reaching out! Please fill out the form below. Your preferred staff member will reach out to you to schedule an appointment. You will then receive an electronic pass or a meeting link (if virtual). Please provide contact information in the event that a staff member needs to contact you on your non-in-person day.
Name (First and Last)
What Wellness Center Staff member would you like to meet with?
Ms. Gentry (Housing/Resource Specialist)
Any Available Wellness Staff
Please Describe Concern
Grief and Loss due to COVID
Don't want to identify on form
What kind of appointment would you like?
Indicate if you are an in-person or VLA (virtual) learner
Virtual Learning Academy
Preferred contact information
Voice Call: List number in additional information below
Email: List email in additional information below
Additional Information (including contact information)
Never submit passwords through Google Forms.
This form was created inside of South Washington County Schools.