JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Behavioral Health Services Interest Form
Formulario de interés de servicios de salud conductual
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Preferred language/
Idioma preferido
*
Choose
English
Español
Student Name -
Nombre del estudiante
*
Your answer
Student School Site -
Sitio de la escuela del estudiante
*
Choose
Camino Real Elementary
Glen Avon Elementary
Granite Hill Elementary
Ina Arbuckle Elementary
Indian Hills Elementary
Mission Bell Elementary
Pacific Ave Elementary
Pedley Elementary
Peralta Elementary
Rustic Lane Elementary
Sky Country Elementary
Stone Ave Elementary
Sunnyslope Elementary
Troth Street Elementary
Van Buren Elementary
West Riverside Elementary
Del Sol Academy
Jurupa Middle School
Mira Loma Middle School
Mission Middle School
Jurupa Valley High School
Patriot High School
Rubidoux High School
Nueva Vista Continuation High School
School Readiness Center (Headstart/Preschool)
Non-JUSD / Fuera del area de JUSD
Virtual Learning Student? -
¿Alumno de aprendizaje virtual?
*
Yes / SÍ
No
Think Together Student? -
¿ Alumno de Think Together?
*
Yes / SÍ
No
Student Grade -
Grado del estudiante
*
Your answer
Parent or Guardian Name -
Nombre del padre o guardián
*
Your answer
Parent Phone Number -
Número de teléfono del padre o guardián
*
Your answer
(School Site) Was the parent informed that the interest list is being completed on their behalf?
(Sitio escolar) ¿Se informó al padre/tutor que la lista de interesados se está completando en su nombre?
Choose
Choose
Yes / SÍ
No
Insurance Type -
Tipo de seguro
*
Choose
Riverside County Medi-cal - Medi-cal con el condado de Riverside
Out-of-County Medi-cal - Medi-cal fuera del condado
No Insurance - sin seguro
Kaiser (Employer Benefits) - Kaiser (beneficios proporcionados por el empleador)
Anthem Blue Cross PPO/HMO
Aetna
Other - otro
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jurupa Unified School District.
Report Abuse
Forms