Counseling Referral Request BHS

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for visiting the Counselor Request Page. While school is being conducted remotely counselors are still available to support students’ social, emotional, academic, and college/career needs. All requests will be responded to as soon as possible via email. You may also request a zoom meeting with your Counselor or with Ms. Marwick in the College and Career Center. Note: If you need to talk privately with a counselor a parent/guardian will need to send a quick note of approval via email

***IMPORTANT: If you think you (or your child) are having a medical or mental health emergency go to the nearest hospital. Do not attempt to access emergency care through this website. You may also call the Benicia Police Department (707)745-3412 or 911 and ask for a "welfare check" and an officer can come to your home and provide transport safely to the hospital if necessary.

Here are some additional resources:

24 Hour Suicide/Crisis Hotline 1-800-273-TALK (8255)
CrisisTextLine.org | Text from anywhere in the USA to text with a trained Crisis Counselor: Text HOME to 741741
Peer-Run Warm Line (1-855-845-7415) is a non-emergency resource for anyone in California seeking emotional support via phone and web chat for problems around interpersonal relationships, anxiety, panic, depression, finance, alcohol and drug use, and more.
Please refer to the district website for more information.

Student Name *

Please write first and last name.

Student Name *

Enter again to verify. Please write first and last name.

Staff Name *

Please check the box of your assigned counselor (if known)

Smith (9th grade)

Guenther (10th grade)

Keppel (11th grade)

Wallace (12th grade)

Marwick (College & Career Center)

Reason For Request *

(Check all that apply)

URGENT Personal Issue

Non-Urgent Personal Issue

Schedule Change

College and Career

Letter of Reccommendation

Academic Concerns

Discipline Follow-Up (Administrator only)

Other:

Required

Briefly Describe the Reason For Referral: *

Person Making Request *

Self

Teacher

Friend or Peer

Administrator

Parent

Other staff

Other:

Preferred Periods to be Seen

(Check all that apply)

Email appointment

Phone appointment

Zoom Appointment (parent/guardian must email counselor to give permission)

Student grade

9th

10th

11th

12th

Clear selection

Race/Ethnicity *

Check all that apply

American Indian/Alaska Native

Asian

Black or African American

Hispanic/Latino

Native Hawaiian/Other Pacific Islander

White

Race Not Listed/Other

Decline to State

Required

Please list your email or phone number for contact and appointment scheduling:

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Benicia Unified School District. Report Abuse

Forms