Counseling Request Form Question Title * 1. Full Name Question Title * 2. Birth date Date / Time Date Question Title * 3. Grade Question Title * 4. Phone number you want to be contacted at Question Title * 5. Student email Question Title * 6. Reason for requesting counseling session? Anxiety Depression Suicidal Thoughts Self-harm behavior (cutting) Family issues Relationship issues Neglect/abuse I’d rather not answer Other (please specify) Question Title * 7. If you are having an emergency or crisis please call 911 or the 24/7 crisis hotline 877-928-9062. This is not an emergency. This is an emergency, and I have contacted crisis or 911. Done