Student Self-Referral Form

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Student Self-Referral Form

Please answer the following questions. If this is an emergency talk to a trusted adult immediately.

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* Indicates required question

Email *

Your email

Student's First Name *

Your answer

Student's Last Name *

Your answer

I need help with: *

Friends

School

Family

Other:

Required

How big is your problem? *

Tiny

1

2

3

4

5

Huge

What would you like me to know?

Your answer

Submit

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