Request to speak to a Counselor or Social Worker

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Want to talk about something or worried about a friend? Fill out this form and someone will be in touch.

***IF THIS IS AN EMERGENCY, PLEASE CALL 911 or text HOME to 741741 for 24/7 Crisis Support with Crisis Text Line***

Email *

Your Full Name *

Grade Level

What do you want to talk about? *

My Friends

My Family

My Teachers/ School Work

Myself

Other:

Tell me more about your concern.

How Urgent is your Concern? *

It is very important (Immediately/ASAP)

It is important (Within 24 hours)

It is semi-important (Within the week)

What is the best way to contact you? *

Phone

Zoom Call (invite will be emailed to you)

Other:

If phone or email, please list the specific email address or phone number.

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

reCAPTCHA

Privacy Terms

This form was created inside of Minooka 201.