YWLA Counselor Request Form

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Greetings!

The purpose of this form is for staff or students to request for counseling support. When completing the form please select if you are the student or staff completing the form.

Thank you for making the decision to reach out for support. As a reminder, if you are on campus and are thinking about hurting yourself or if someone is hurting you, inform an adult IMMEDIATELY. If you are not on campus and are thinking about hurting yourself or if someone is hurting you, call 911 IMMEDIATELY.

No matter where you are learning from or what you may be going through, please know that I am here to support you.

To schedule a meeting with me, complete each section below and I will respond to your request as soon as possible.

With Kindness,

*CONFIDENTIALITY DISCLOSURE: Information shared on this form is seen by Ms. Gash and will not be shared with anyone UNLESS you disclose safety concerns (such as you wanting to hurt yourself, someone is hurting you or you want to harm others)

Who are you? *

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