How to Connect with your School Counselor

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If this is an emergency (you feel like you or someone else is in danger), please do not continue with this form.
This form is not monitored 24/7 and is not intended for crisis intervention.

1). Immediately tell a trusted adult what is going on. A trusted adult can include your
parent, adult neighbor, an adult family member, a friend's parent, an adult from your
church, etc.
OR
2). If you feel you do not have a trusted adult to go to, call 911 if you or someone else is in
physical danger.
OR
3). If you feel you do not have a trusted adult to go to and are having thoughts of harming
yourself or others, call the Life Paths Crisis Center 877-422-5939

Then, complete this form so that I know to follow up and check on you!

Student's First Name *

Student's Last Name *

Parent/Guardian filling out request *

Grade *

Pre-Kindergarten

Kindergarten

I need help with (click all that apply) *

an emotional need (stress, worry, anger, sadness, etc.)

I feel unsafe or am being harmed (remember, this is an emergency! Find your trusted adult or call 911 if you need immediate help).

food

school work

Other:

Required

How would you like to connect with me? *

in an email (leave your email address next to the "other" label)

in a video meeting (I will email you a time to meet and a link to join join a Google Meet video chat).

through a phone call (leave your phone number next to the "other" label).

Other:

Message for the counselor:

Submit

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