Student Self-Referral

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I need someone to talk to and would like a visit with the school counselor.
This is a confidential way to speak to a counselor directly without anyone knowing. I appreciate you reaching out for help!
Please understand that if you choose to stay anonymous, it makes it difficult for us to contact you or communicate our responses and/or concerns. The choice is yours to share your name or remain anonymous, we are here for you no matter what and respect your choice.

Email *

What would you like to report? Give your statement below; *

Name: *

School *

Elementary

Middle

High

Concern-Issue *

Friends/Relationships

Grades

Home/Family

Emotions-Sad, Anxious, Scared, Angry

Teacher conflict

Other:

Best time to pull you out of class *

Crisis-I need to talk to someone immediately *

Hurting Self

Hurting Others; either you feel you want to or you are aware of someone wanting to

Someone is hurting you or threatening to

None of the Above-it is not an emergency

Best number to contact you if not at school

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