AFS Counseling Referral
Meet with our Adolescent and Family Services Counselor, Dylan Cromartie, for on-site support around mental health and substance use. Dylan is available in room H0-A for one-time check-ins as well as ongoing support. There is no commitment necessary.

Please answer the questions below. Dylan will reach out directly to schedule an appointment following your submission. Walk ins are also welcome Monday and Wednesday 10am to 2pm in Room H0-A.
Sign in to Google to save your progress. Learn more
Everything you share with an AFS Counselor will remain private and kept confidential, unless we get written permission from you to share information to help coordinate care.

Your safety is very important to us, and as mandatory reporters, there are limits to confidentiality under certain circumstances, including an intent to act on thoughts of suicide or harm to others, and reasonable concern regarding the abuse of a child, elderly person, or disabled person.


Relationship to Student *
Student ID# *
Student FIRST Name *
Student LAST Name
Student Phone # (or best way to get in contact with student) *
Student Email *
Student Pronouns *
Student Grade *
Preferred Language *
Caregiver Phone # (if appropriate)
Caregiver Email (if appropriate)
Reason for Referral *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dylan's Workspace. Report Abuse
Google Forms