Care Clinic Referral for MISD Employees

Required

Disclaimer: Any information obtained for this form will be for the purpose of scheduling a counseling session with the CARE clinic and will not be shared with your employer at any time.

The services you receive at CARE clinic are confidential and not associated with your employment with Mesquite Independent School District. Please complete this form to the best of your ability to give us an understanding of your current needs.

Demographic Information


Counseling Needs

Must contain a date in M/D/YYYY format
Must contain a date in M/D/YYYY format

If you are suicidal or this is a true emergency, please dial 911 for immediate assistance.


On a scale of 1-5, please rate how you currently feel.

Current level of anxietyrequired1=low 5=high​
1=low 5=high​
Current level of depressionrequired1=low 5=high​
1=low 5=high​
Current level of stressrequired1=low 5=high​
1=low 5=high​

Appointment Preferences

Please complete the preferred appointment information below. We currently have a waiting list but will try our best to match you with someone as soon as possible. Completing the below information allows us to match a counselor with your availability.

Preferred day of the week: