Student Counseling Self-Referral

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.
Email*
Please enter your email address
Name*

First NameLast Name
Date*

MonthDayYear
Today's date
Grade*
Please choose your grade level
Reason for meeting. Please select all that apply.*

Academic ConcernsPeer RelationshipsFamily ConcernsAnxietyEmotional Well-beingSpiritual IssuesDepressionAddictionSelf-harmOther
Are your parents aware that you are making this referral?*

YesNo
Is this an emergency situation? If "Yes" please inform a BACS staff member ASAP.*

YesNo

Student Self-Referral for Counseling