Counseling Requests (HBHS)

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A request for counseling does not guarantee you will be seen the same day. Appointments are typically made within 1 week. This form is not monitored after school hours, on the weekends, or during school breaks (i.e. winter break, summer).

IF THIS IS AN EMERGENCY, PLEASE CALL 911.

National Suicide Prevention Lifeline: 24/7, 365-day-a-year hotline for people experiencing suicidal crisis or emotional distress. 1-800-273-8255 or click here to chat.

Your Name *

Student ID#

Grade Level *

What is the main concern that brings you in today? *

Relationship Problems (family)

Relationship Problems (girlfriend/boyfriend)

Relationship Problems (friends)

Anxiety (nervousness, worried etc.)

Depression (sadness, loss of interest etc.)

Concern for someone's safety or well being

School Problems (grades, teachers, classes etc.)

Suicidal thoughts

Self harm

Substance abuse

Grief/Loss

Bullying

Eating problems

Vape/Nicotine Addiction

Unsafe home environment

Other:

Required

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

[0 = Not At All] | [1 = Several Days] | [2 = More Than Half The Days] | [3 = Nearly Every Day]

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

1. Little interest or pleasure in doing things

2. Feeling down, depressed, or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual

Please enter your cell phone number so we can best communicate with you. *

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