Counseling Request Form
Hello Knights!

We are very proud of you for reaching out to talk to us! Even though you're learning from a distance, we are here to support you. Please complete the questions below so that we can get a better understanding of what's going on and how we can best support you. Our office hours are from 7:30 am to 4:00 pm, Monday through Friday.

* If this is an emergency or you're not feeling safe, please let a trusted adult know right away or call 911. If you need immediate help during non-school hours, please use the following numbers:

1) Crisis Text Line: text the word "HELLO" to 741741
2) Call the National Suicide Prevention Hotline at 1(800) 273-8255
3) Chat with a trained professional at https://suicidepreventionlifeline.org/chat/
4) Call the TEENLINE at (310) 855-4673 from 6pm-10pm or text 839863 from 6pm-9pm
5) Access more support from TEENLINE at https://teenlineonline.org/
6) Trevor Project Lifeline (Available 24/7; Confidential Suicide Hotline for LGBT Youth): 866-488-7386


* Required
Email address *
First & Last Name *
Date *
MM
/
DD
/
YYYY
Grade *
I am feeling: *
home (family member, health, safety)
school ( technology, difficulty understanding material)
Worried
I am feeling:
I lost someone (death, separation, break up, pet)
I miss my friends
I miss a family member
Unsure of the reason
sad/depressed because:
I need help with:
Clear selection
REMEMBER: If this is an emergency or you're not feeling safe, please let a trusted adult know right away or call 911. I will check this form daily (Monday through Friday), but it may take 24-48 hours (1 to 2 school days) to respond. **WEEKENDS ARE NOT INCLUDED** *
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