SWP Registration

Here is some important information to note before registering for the SWP:

The student will be confidentially called out of class to take the screening tool on their Chromebook, typically in a group setting with other registered students.
Students 17 years old or younger must be registered by their legal guardian.
Students 18 years old or older must register themselves.
Please notify your student that you have signed them up for the SWP, so they are not surprised when they are called out of class to participate.

Students will complete a questionnaire about their thoughts, feelings, and behaviors, including symptoms of depression and anxiety, suicidal thinking and behavior, attention-related concerns and disruptive behavior, and use of drugs and alcohol. All screening results will be kept confidential, stored separately from academic records, and not shared with your student’s teachers, counselors, or administrators without your permission. The only limit to this confidentiality is if it is determined there is an immediate safety risk to your students or others, in which case information necessary to secure safety will be disclosed.

If your student's results indicate a potential concern, we will contact you via email and text (if given permission) to set up a time to talk to a SWP staff person about your student's results and next steps.

If there is a safety concern for your student, an SWP staff member will contact you immediately.

If you have any questions or concerns, please contact the SWP Director, Brian Kuhn, at brian.kuhn@mha-em.org.

Student's First Name*

Student's Middle Name or Initial*

Student's Last Name*

Student Date of Birth*

Parkway Student ID*

Student ID can be found on Infinite Campus

Program Number

Student's Preferred Language*

If other please specify

Does the student need accommodations?*

YesNo

If Yes, Please indicate the accommodation(s) needed

Read the screening to the studentScreen in a seperate roomProvide in a different languageOther (Specify Below)

Other Important Information About The Student/ Family

Guardian First Name (1)*

Guardian Last Name (1)*

Guardian First Name (2)

Guardian Last Name (2)

Relationship to student (Guardian 1)*

Relationship to student (Guardian 2)

Mobile Number (Guardian 1)*

Please enter a valid mobile phone number.

Mobile Number (Guardian 2)

Please enter a valid moblie phone number.

Other Phone Number (Guardian 1)

Please enter a work or other phone number.

Other Phone Number (Guardian 2)

Please enter a work or other phone number

Address (Guardian 1) *

Street Address

Street Address Line 2 (1)

City (1)

State (1)

Zip Code (1)

Address (Guardian 2 if different than above)

Street Address (2)

Street Address Line 2 (2)

City (2)

State (2)

Zip Code (2)

Email (Guardian 1)*

example@example.com

Email (Guardian 2)

example@example.com

Guardian's Preferred Language*

If other please specify

Student Wellness Program Registration

Student Registration Information

Program Enrollment Information