Counselling Self-Referral

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Counselling Self-Referral

This form is confidential and will only be seen by Mrs. Wallace. If you require immediate support please contact the NS Mental Health Crisis Line at 1-888-429-8167 or the Kids Help Phone at 1-800-668-6868.

After completing this form, someone will be in touch will you.

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What is your name?

Your answer

Class?

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Please provide a brief description of the problem/issue:

Your answer

On a scale from 1-10, how serious is this issue, 1 being not-that-serious and 10 being very serious:

Choose

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10

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