VSSA Counseling Support Referral Form
COUNSELING REQUEST FORM: Please fill out the form below to request a meeting. Allow 1-7 days for them to get you. If this is something that is time sensitive please rate your issue/concern as a 5 at the bottom.
Counselors DO NOT respond to meeting request forms outside of school hours.
If this is an emergency, please call 911 or the Hope Center Crisis Line at (970) 306-4673.
Call Safe-To-Tell to anonymously report any safety concerns::
Name of person completing this form:
Relationship to student of concern
I am referring myself
I am a Parent , Coach or teacher requesting resources or support for myself.
Student's First Name
Student's Last Name
I am a parent, coach or teacher
Who would you like to see
Either is fine
Are you or anybody else in danger in someway? *(harm to self or others)
IF YES TO ABOVE QUESTION PLEASE TELL ME MORE....
I need to talk with you about: *
URGENT!! Something private right away! (please give a few details below)
Loss or Grief
Stress or Anxiety
Family Problems (divorce, parents, brothers/sisters, other)
How others are treating me (or your student)
Feeling Better about myself
Peer Pressure/ Not being able to say "no" and "stop it" when I don't want to do something
Thinking about hurting myself or someone else.
My grades or schoolwork
Substance abuse (drugs, alcohol)
Covid Related Challenge (Stress or Loss)
Other Concern (Please explain below)
Other comments or information about what is occurring
Please rate the issue or concern on a 1 – 5 scale. 1 = Something is wrong and would like to talk to talk to someone this week. 5 = I need to talk to you as soon as possible.
***Counselors DO NOT respond to meeting request forms outside of school hours.*** If this is an emergency, please call 911 or Hope Center Crisis Line at (970) 306-4673. Call Safe-To-Tell to anonymously report any safety concerns:: https://safe2tell.org/
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This form was created inside of Aspen Hope Center.