Request to Meet With Wellness Counselor 25-26

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RUHS provides professional mental health services to students in their academic setting. Our therapist and counseling interns are conveniently located right on campus. All services are free to the student and their parents. To request an appointment with a Wellness Center Counselor, please fill out the form below. We will try to see you as soon as possible. A blue slip will be sent to your class with the designated time. If you need to miss the appointment, please email us immediately so we can schedule someone else in that spot. If this is a mental health crisis, please contact 988 or go to your nearest hospital. If you or someone you know is in danger, please call 9-1-1. We look forward to meeting with you. You are very valuable to us.

Email *

Student Last Name *

Student First Name *

Grade Level of Student

9th

10th

11th

12th

Clear selection

Have you or the student you are referring ever met with a Wellness Center Counselor? *

Yes, I have met with a counselor at the Wellness Center

No, I have never met with a counselor at the Wellness Center

I can't remember/don't know

Which Wellness Center Counselor would you like to see? *

First available

Maya Daley, PPS, LMFT (M-F)

Maddie Schonberg, Intern (Mondays, Thursdays)

Aidaley Galan, Intern (Tuesdays and Wednesdays)

Karol Hernandez, Intern (Tuesdays, Fridays) Speaks Spanish

Peer Counselor (students trained to help other students)

What type of meeting are you requesting? *

Quick Check-In (Under 20 Minutes)

Individual Counseling Session (20-50 Minutes)

Crisis Counseling (Emergency- someone could be hurt, please come in person immediately)

Parent Consultation

Other:

Who is referring the student for services? *

Myself (student)

Parent

Staff

Teacher

What time frame would be best? *

The student would like to see a Wellness Counselor/Counseling Intern within a week or so

The student would like to see a Wellness Counselor/Counseling Intern Within a few days

The student is in crisis and needs to see someone by the end of the day (crisis= someone may be in danger i.e. self-harm, child abuse, etc) **crisis requests made at the end of the day may not be seen, so please go straight to the office**

How would you prefer we contact the student for the appointment? *

Call Slip

Other:

Required

Please provide best phone number or email to reach you at: *

Please explain your request so we can be fully prepared for our meeting. What should we know? *

I consent to services understanding that there are benefits to getting counseling support, and I can stop services at any time. I acknowlege that counseling is confidential, unless someone is harming me, or if I have plans to hurt myself or others. I understand that a counselor or an intern counselor in training may work with me in an individual, group, or ongoing setting to provide services. I know that this service is completely free and provided to me as a student at RUHS. Please write your name in the box to confirm. Thank you! *

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