• Student Self-Referral for Counseling

    Submitting this form will notify Mr. Ammons that you would like to schedule a meeting with him. After receiving this meeting request Mr. Ammons will schedule a time to meet with you within a one week period. If this is an emergency situation that requires attention before the end of this school day please indicate that in the appropriate spot on this form and inform a BACS staff member ASAP.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Reason for meeting. Please select all that apply.*
  • Are your parents aware that you are making this referral?*
  • Is this an emergency situation? If "Yes" please inform a BACS staff member ASAP.*
    • Start non-emergency 
    • If you have an open period in your schedule, like a study hall, please enter the time that period begins.

    • Statement on Confidentiality

      Confidentiality is a crucial part of the counseling relationship. However, there are limits to confidentiality, especially if there is a risk of harm to yourself or others.

       

      Thank you for taking this step to seek support. I look forward to speaking with you.

      - Mr. Ammons

    • Image field 28
    • End non-emergency 
    • Start emergency 

    • Thank you for reaching out. To provide timely support in addressing this situation before you leave school today, please go to the front office on your campus and inform a BACS staff member that you are in need of immediate assistance in dealing with an emergency situation.

    • Will you go to the front office and inform a BACS staff member?

    • Statement on Confidentiality

      Confidentiality is a crucial part of the counseling relationship. However, there are limits to confidentiality, especially if there is a risk of harm to yourself or others.

       

      Thank you for taking this step to seek support. I look forward to speaking with you.

      - Mr. Ammons

    • Image field 30
    • Stop emergency 
    • Should be Empty: