Request for Counseling Appointment
This form is to let your counselor know you would like an appointment. Parents, guardians and students can complete it.

We will contact you via email or phone with your appointment time after we receive and review the answers on this form. Detailed responses are appreciated so your counselor knows how to assist you.

If you think you are having a psychiatric emergency, there are resources available to you. The National Suicide Prevention Lifeline can be reached at 1-800-273-8255. You can also contact your primary care provider or go to the nearest hospital. If you are in immediate danger, please contact the Vacaville Police Department at 707-449-5200 or by dialing 911.
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Email *
Who is completing this form? *
What is student last name?
What is student first name?
If parent or guardian is requesting appointment, what is your full name?
Student Current Grade Level:
Clear selection
1. Who would you like to meet with? Counselor Name - alphabet ranges are by student last names/ programs *
2. What will you be discussing? *
3. Please give some details about your needs/what you want to discuss.
4. Please select preferred method of appointment / communication *
5. What is your personal email address? *
6. What is your cell phone number? *
Clear form
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