School Mental Health Referral Form -        Narbonne High School  2021-2022
Please complete this form, if you are in need of mental health services for your student.  Ms. Kono, LCSW/PSW will respond to your referral as soon as feasible, weekdays from 8:00 a.m. - 4:30 p.m.  

If this is an emergency, please call 911. Aside from referring student to the PSW, if you are in need of additional mental health or community resources, please call Los Angeles Unified School District Wellness Hotline (213) 241-3840 from 8 a.m. - 5 p.m. Monday-Friday.

In the event a student is experiencing suicidal or homicidal issues, Assistant Principal Ms. Flores (or another administrator) and PSW Ms. Kono (or a crisis team member must be informed immediately.)  If you are unable to reach anyone, please call the LAUSD Wellness Hotline.  Thank you.
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Email *
Name of Person Making Referral *
Position of Person Making Referral *
Student's First Name *
Student's Last Name *
Student's ID Number or Birthdate (if accessible)
Student's Phone Number (if available)
Student's E-Mail Address
Parent(s)/Guardian(s)' Name(s):
Parent(s)/Guardian(s)' Phone Number(s):
Parent(s)/Guardian(s)' E-Mail Address (if available):
Student's Grade Level
Clear selection
Is student in general or special education?
Clear selection
What are the student's strengths and/or interests?
What is/are the reason(s) for referring this student? (check all that applies) *
Required
Specific Concerns/Additional Comments:
Thank you for completing this PSW referral.  PSW will contact student and parent/guardian and follow-up with referral source via e-mail as soon as feasible.  If it is an emergency, call 911.  If student is in crisis, contact an administrator and crisis team member immediately.  
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