Counseling/Therapist Request 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. What are you struggling with? Anxiety Depression Relationship Problems Family Issues COVID-19 Struggles Abuse/Neglect ADHD/Focus Suicidal Thoughts Self-Harm I'd prefer not to answer Other (please specify) Question Title * 7. If this is a crisis situation or an an after school hour emergency, please call the Crisis Hotline at 1-877-928-9062, call 911, or go to your nearest Emergency Room. This is not an emergency I understand that if this is an after hours crisis situation, I need to contact the Crisis Line above or go to the nearest emergency room. Done