Counseling referral form

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2020-2021 Rancho San Joaquin Middle School- Counseling Referral

The counselors are available Monday-Friday from 8:00 AM - 3:00 PM (except holidays/breaks).

If this is an EMERGENCY and you do not have immediate access to the counselor, please speak to a trusted adult ASAP, call 911, or call the Suicide Prevention Lifeline : 1.800.273.8255.

Email *

Academic Model of Student *

Hybrid at Rancho

Irvine Virtual Academy

What is your full name? *

What is the name of the student you are referring? *

Person referring the student *

Student

Parent/Guardian

Student Grade Level *

7th

8th

What is the best time of day to contact you? *

8:00-10:00 am

10:00-12:00 pm

12:00-2:00 pm

2.00-3.30 pm

Is the Student Aware of the Referral? *

Yes

Is the student on an IEP/ part of Special Education? *

Yes

Reason for referral. Please give specifics of the area of concern. *

How urgent is this matter? *

Level One- the student will be contacted within a week

Level Two- the student will be contacted as soon as possible (within the next 24-48 hours)

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