Submit a Request for Student Mental or Behavioral Health Services
Our school district strives to promote mental health awareness and access to mental health services in our schools to increase health and wellness of students, families, and the community. Please use this form to submit requests for counseling, support, or intervention services for your child experiencing emotional or behavioral concerns.

This form is to be completed by parents/caregivers of students in Lawrence County schools.

Form1C
Date Submitted *
MM
/
DD
/
YYYY
Student Information
School: *
Student Legal Name (First and Last) *
For example: Elizabeth Johnson
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student Grade Level *
Student Gender *
Student Race/Ethnicity *
Required
Next
Never submit passwords through Google Forms.
This form was created inside of EMT Associates, Inc.. Report Abuse - Terms of Service - Additional Terms