Mental Health Therapy Appointment
Name
*
First Name
Last Name
Glenbrook ID Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Mode of Communication to Receive Outreach/Scheduling Information:
*
Text
Email
Phone Call
No Preference
Campus
*
GBA
GBN
GBO
GBS
Other
Student or Staff Member
*
Student
Staff
Current Grade (If a Student)
Appointment Inquiry
*
First Appointment
Follow-Up - I have attended a therapy session with Mrs. Jefferson, LCSW during the current school year.
I am not sure
Preferred Appointment Type
*
In-Person
Virtual
No Preference to In-Person or Virtual Visit
Availability of Appointment (check all that apply)
Gold Block 1
Gold Block 2
Gold Block 3
Gold Block 4
Blue/Green Block 1
Blue/Green Block 2
Blue/Green Block 3
Blue/Green Block 4
I am not sure
If you are comfortable, please share anything, including symptoms or problematic experiences, that will prepare for our session. This question is not required.
Insurance Information (we do not bill for these services, however, is helpful for accessing resources)
Medicaid
Private Insurance
No Insurance
I am not sure
How did you hear about mental health services at Glenbrook School Health Center? (check all that apply)
Doctor/Provider
School Staff
Friend
Online Search
Marketing Event
Other
Submit
Should be Empty: