Capital School District Counselor Communication Request

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Please fill out this form entirely if you are in need of social or emotional resources or support. We will respond via your preferred method of communication.
*This form is not intended for emergencies. If you have an emergency, please dial 9-1-1 immediately.

Email *

First name of student *

Last name of student *

Name of person completing this form *

Person completing this form (relationship to student) *

Parent/Guardian

Student

Other:

Phone number of person completing this form *

Email address of person completing this form *

Preferred method of communication *

Phone

Other:

Select School *

Grade of student *

Area of Concern *

Academic (School work, college planning, career, etc.)

Social/Emotional/Personal (Anxiety, Stress, Conflict Resolution, etc.)

In need of resources (financial, employment, food, shelter, etc.)

Check in

Other:

Comment/Question (ie. a request to speak to a specific person, question about district meal distribution, etc.) Please do not provide confidential or personal information here. *

Submit

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