Family Request for Counselor Contact Form
The information on this form will be sent to the Jefferson Counseling Department. It will be used to address family and student needs during the at home learning plan with APS.
Student First Name *
Student Last Name *
Student Grade *
Person completing the form *
Relationship to student *
Best way to contact you (please include the contact information) *
Staff member you would like to speak to:
Reason you are reaching out and support needed?
On a scale of 1 to 10, please rate your level of concern (10 being the greatest concern).
Clear selection
If you or a family member is experiencing a mental health crisis (threats of harm to self or others), please call 911. If you or a family member is experiencing any kind of emotional crisis, mental health or substance use concern, you can find help 24 hours a day, seven days a week, by calling the New Mexico Crisis and Access Line at ​1-855-NMCRISIS (1-855-662-7474) or ​Peer to Peer Warmline ​at 1-855-4NM-7100 (1-855-466-7100). nmcrisisline.com *
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