Connect Form
This form is confidential, and will be sent only to members of the Student Support Services Team to provide support for the respondent. All information is to be treated as confidential, including the fact that the respondent receives (or previously received) services. The privacy and confidentiality of respondents are protected under the Ethics Codes of the mental health professions, state laws and regulations, and federal HIPAA Regulations. No respondent information may be disclosed without the explicit informed consent of the respondent and authorization by their clinician.
Sign in to Google to save your progress. Learn more
What school? *
Student's Name *
Your Name *
Relationship to Student
How can we help you? *
Contact Information *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dodge County Schools. Report Abuse