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24-25 Student Services Check In
This form is monitored within school hours only.
If you or someone you know is experiencing a mental health emergency, please call 911.
Additional Resources:
BPS101 Safety Help Line:
https://www.bps101.net/safety-help-line/
Safe2Help Illinois:
www.safe2helpil.com/
BPS Virtual Calming Room:
https://sites.google.com/bps101.net/bpsvirtualcalmingroom/home
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Last Name
*
Your answer
Grade
*
Choose
6
7
8
Team
*
6.1
6.2
6.3
7.1
7.2
7.3
8.1
8.2
8.3
I have attempted to use a strategy (calm classroom, mindfulness, deep breathing, etc.) prior to making a request to come to Student Services.
*
Yes
No
Reason for Visit?
*
Choose
Nurse Visit
Bus Issue
Concern with peer incident
Concern for my safety
Concern for the safety of others
Make a Phone Call (For emergency purposes only)
Referred by Teacher
Other
Appointment Type:
*
Choose
I have a scheduled appointment
I requested to meet with someone
My teacher or another staff member requested the meeting
Other
Adult I am here to see today?
*
Choose
Counselor- Mrs. Webb (6th Gr.)
Counselor- Mrs. Heidgen (7th Gr.)
Counselor- Mrs. Neece (8th Gr.)
Social Worker- Mrs. Christiansen
Social Worker- Ms. Carney
Social Worker- Ms. Tellis
Nurse (If selecting nurse, please submit this form, get permission from your teacher first prior to coming down to the Nurses Office.)
Phone (For emergency purposes only. Must receive permission from teacher first prior to coming down to St. Services.)
Dean- Mr. Arduino
Dean- Mrs. Smith
Level of impact this issue has on my day?
*
I need to speak to someone this week.
1
2
3
I need to speak with someone as soon as possible
Any additional information you would like adult(s) to know about why I'm visiting?
Your answer
Submit
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