How can we support you?
Our school district strives to promote the health and wellness of our students, families, and communities. Use this form to request counseling or support services through your school district to get help with any problems or issues that you or someone close to you may be experiencing. Complete the form, click the submit button, and your request will be sent to a service coordinator who will contact you to schedule a meeting.
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Date Submitted *
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Student Information
School: *
Student Legal Name (First and Last) *
For example: Elizabeth Johnson
Your answer
Student Date of Birth *
MM
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DD
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YYYY
Student Grade Level *
Student Gender *
Student Race/Ethnicity *
Required
Your Phone Number (Optional)
Your answer
Your Homeroom Teacher (Optional)
Your answer
Request Information
Reason(s) for Request: In two to three sentences, let us know what is going on with you.
Your answer
Is there someone you would prefer to speak with about the request?
Submit
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