REMOTE Counseling Appointment Request 2020 - 2021 (HBHS)
***This form is to be completed by students requesting counseling. If you are a parent or teacher with a concern about a student, please contact us directly hbhsgrouppsychologists@hbuhsd.edu

IF THIS IS AN EMERGENCY CALL 911

By completing this form, you are agreeing to communicate with an HBHS school psychologist or counselor via phone call, text message, email or video conference. Response times may vary, depending on the volume of requests, date received, or time of day.

NO IN PERSON COUNSELING WILL TAKE PLACE AS A RESULT OF FILLING OUT THIS FORM.

Throughout the communication process, if the psychologist or counselor determines there is a risk to your safety or the safety of others, they will contact another adult which may include parent/guardian, psychologist, administrator, or first responders.

IMPORTANT PHONE NUMBERS:

Crisis Text Line
Text START to 741741 any time

Suicide Prevention Lifeline
1-800-273-8255, text ANSWER to 839863

California Youth Crisis Line
1-800-843-5200
Agreement: *
Required
Preferred Form of Counseling: *
Your Full Name *
Student ID#
Grade Level *
What is the main concern today? *
Required
Over the last 2 weeks, how often have you been bothered by any of the following problems? *
0 = Not At All, 1 = Several Days, 2 = More Than Half The Days, 3 = Nearly Every Day
0
1
2
3
1. Little interest or pleasure in doing things 
2. Feeling down, depressed, or hopeless 
3. Trouble falling or staying asleep, or sleeping too much 
4. Feeling tired or having little energy 
5. Poor appetite or overeating 
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television 
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Best phone number to reach you for Text or Phone Call:
Any other info:
Submit
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