Don Juan Avila Elementary School Counseling Parent/Family Referral Form 2023-2024 School Year
Contact Information for School Counselor, Ms. Gomez
Email: jigomez@capousd.org
Phone number: (949)362-0348
Ext. 81013

NOTE: If this is an EMERGENCY and you do not have immediate access to a counselor, Call 911, or call the Suicide Prevention Lifeline 1 800-273-8255 or text 988.
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Please complete the following form: 
Parent First and Last Name *
Today's Date
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DD
/
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Student's First and Last Name *
What is your relationship to the student? *
Required
Grade Level *
*
Reason for Referral (Select all that apply) *
Required
Please provide a brief description of your reason for referral: *
Do you think the student would benefit from a small group? (Depending on student interest and need). *
What small group best suit the student's need?
(PLEASE READ: This is not a guarantee as small groups depend on need of the school at the time.)
How would you like the counselor to reach you? *
What is the best phone number or email to contact you? *
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