Serenity Space Request & Referral for Support

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Thank you for reaching out for support! For student access to the Saugus Serenity Space, please complete this form. When we receive your request we will have a Campus Supervisor escort the student from their current location to the Serenity Space. We are happy to support you as soon as we can!

Email *

Record my email address with my response

Request/Referral Made By *

Myself (Student)

Teacher/Staff

Student's Full Name *

Reason for Request *

Need someone to talk to.

Feeling anxious, sad, angry, or other emotion, and need a safe space. May need to talk.

Need a break or quiet place to refocus or regroup. Doesn't want to talk to anyone.

What is the student's current location? *

I hereby certify that I am 12 years of age or older and I am the individual stated above to seek out mental health support services from Krystal Dickerson at my school wellness center and/or school social worker’s office. *

Yes

For Staff and Teachers: I am filling this form out for a student. Student will be able to give consent in the Serenity Space.

So glad you reached out! Someone will assist you soon.

Submit

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