Contact Us

Once the form is received I will try my best to reply via phone or email within 24 hours (not including weekends) and then schedule a meeting time.

Student's First and Last Name

First Name

Last Name

Student's Grade Level

Your first and last name

Students who are filing this form out for themselves do not have to fill this section out.

First Name

Last Name

Relationship to Student

Email or Phone Number

Preferred Contact Method

Is the student currently seeing a counselor?

Reason for Request

Confidentiality

I accept the rules of confidentiality

**What is discussed during counseling is confidential; however there are some exceptions to confidentiality that are provided to protect yourself and others. Confidentiality will be broken if you disclose that you are being physically or emotionally abused or neglected, and/or have a serious intent to harm yourself or others. **