Request for Mental Health Services
Student Name:
First Name
Last Name
Mentor Name
First Name
Last Name
How would you rate your current mental health on a scale of 1-10. 1 meaning you are in a great mental space, 5 meaning you are tipping the edge of feeling out of control or needing help, 10 meaning you are in crisis.
I have utilized the free mental health services, provided through school services
Please Select
Yes
No
If yes, describe your experience. Was this a positive/negative experience, did you find the sessions helpful or meaningful?
Please describe your current mental health challenges or goals and what you hope to accomplish through Fostering Success supported therapy?
Is this an emergency or does this need require an immediate response? If yes, please contact 911 or reach out to the Suicide Prevention Hotline at: 800-273-8255.
Yes
No
Submit
Should be Empty: