Virtual Contact Counseling Request - Student
Please complete form for virtual counseling request. I will contact via email or phone. Please use your school email address. Looking forward to connecting with you!
Student First & Last Name:
Name of School:
Perceived urgency of need: (If you are feeling unsafe to yourself or suicidal - please call 911 or call the suicide hotline (800)273.8255 - please reach out to an adult for immediate help.
1. Urgent (imminent danger to self or others or experiencing abuse/neglect at home.)
2. As Soon As Possible (loss, depression, anxiety, needs clothing, food)
3. When Convenient (non-emergency)
What is the best time to call you morning or afternoon?
What is your phone number?
Virtual/Distance School Counseling Confidentiality- by checking the box you understand confidentiality in school counseling and limitations of confidentiality. Confidentiality is of the utmost importance between student and school counselor and is maintained at all times with the following exceptions: (1) Report of harm to self or others (2) Abuse or neglect (3) Court, other legal proceedings.
Yes, I understand the confidentiality guidelines.
No, I do not understand the confidentiality guidelines.
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This form was created inside of Central Point School District 6.