NMS Counseling Request & Referral Form

Welcome to the NMS Counseling Office. Please use this form to request social-emotional, academic, or behavioral support for your student.

⚠️ Important Safety Note: This form is checked during standard school hours only. If your child is experiencing an immediate mental health crisis, self-harm emergency, or safety threat, please call 911, contact the Suicide & Crisis Lifeline at 988, or go to the nearest emergency room.

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Parent/Guardian name *
Parent/Guardian email address
Parent/Guardian phone number *
Student full name *
Student grade level *
Urgency / Expected Timeframe
What primary area would you like us to focus on? *
  Briefly state any concerns or goals for your student:   *

Permission for Counseling Services

I give permission for the NMS Counseling Office to meet with my student to provide academic, behavioral, or social-emotional support.

 *
Required

Limits of Confidentiality 

I understand that information shared during counseling sessions is confidential, except in cases of suspected child abuse/neglect, threats of harm to self, or threats of harm to others, as required by law and professional ethics.

 *
Required

Parent Collaboration 

I understand that home-school collaboration supports student success. I agree to partner with the counselor and support suggested strategies or activities at home when helpful.

 *
Required

Post-Session Support *

I understand that students may experience heightened emotions after processing difficult topics, and I will assist in supporting my child’s emotional well-being at home if contacted by the counselor.

 *
Required
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