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
Person completing the form
Relationship to student
Adult family member
I am the student
Best way to contact you (please include the contact information)
Staff member you would like to speak to:
Katrice Grant (6th Grade Counselor)
Stacey Sieberg (7th Grade Counselor)
Michele Hardwick (8th Grade Counselor)
Reason you are reaching out and support needed?
Supportive conversation with counselor
Personal issues at home
Social issues with peers
Resources: School supplies
Technology support: Connectivity issues
Technology support: Device need
Referral to external agency
On a scale of 1 to 10, please rate your level of concern (10 being the greatest concern).
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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This form was created inside of Albuquerque Public Schools.