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COST Student Self-Referral (web)
Please complete this form to request mental health and/or academic support.
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Email
*
Your email
If you are experiencing suicidal thoughts or if you do not feel safe please call 911 or ask to be taken to your site principal for immediate assistance.
First Name
*
Your answer
Last Name
*
Your answer
Student ID Number
*
Your answer
Contact Number
*
Your answer
Contact email
*
Your answer
Please indicate what type of support you need.
*
Academic Support
Mental Health Support
Academic and Mental Health Support
Other:
Please provide a brief description what's going on.
Your answer
Send me a copy of my responses.
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