Evergreen Elementary School-Based Mental Health Support: Request for Appointment
Please use this form to request an appointment with CRPUSD school-based mental health support. Appointments will be conducted either via video conferencing or by phone. Please note that these remote appointments are not intended to replace the student’s medical care or services provided by an outside mental health care provider. These services are intended to support students in identifying and managing difficult feelings, and in developing effective coping strategies during these challenging times. A school-based professional will contact you within two school days (Monday – Friday).
Important: This is not a crisis line. For crisis support dial 911 immediately, or one of the following resources listed below:
• Sonoma County crisis stabilization unit (707) 576-8181
• Sonoma County Suicide Prevention Hotline: (855) 587-6373
For additional wellness or mental health support, check out the CRPUSD External Distance Learning Resources at
If you have questions about classes or academics, please contact your school’s counselor or administrators.
If you have concerns about a friend, remember you can still use the STOPit app on your phone at any time to report an issue anonymously. School administrators check STOPit app reports every day.
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Who are you?
Student's Last Name:
Student's First Name:
Student ID Number (if available):
Please indicate some of the concerns you would like support around (mark all that apply):
Feelings of sadness and depression
Feelings of fear, nervousness, or anxiety
Feeling isolated or lonely
Feelings of anger or frustration
Financial concerns (income, food, or housing scarcity)
Anxiety about grades or academics
Help finding mental health support/other resources
Are you currently receiving, or have you received in the past, mental health services or support from a staff member at your school?:
I don't know
If yes, please indicate who provided the support:
A CRPUSD school-based mental health professional will contact you to arrange for an appointment time. How would you like to be contacted?:
Please provide your phone number and/or email address below so we can contact you to set up an appointment time:
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This form was created inside of Cotati Rohnert Park Unified School District.