Non Emergency Support Request Form
STUDENTS:
• If you have thoughts of suicide immediately call the Suicide Prevention Hotline at 800-273-8255.  Please provide us with your name and number so we can follow up.

REMEMBER: Talk to your parents, a favorite teacher, counselor or principal—help will be provided as your well-being is our priority.

TEACHERS/STAFF:
• If your concern pertains to a student's social emotional well-being, please talk with the school psychologist or counselor

PARENTS:
• If you are concerned about your student's social emotional well-being, and have been for two weeks or more, please complete the referral form below.  

If this is an emergency, please call 911 or take the student to the nearest hospital.  Fill out the referral form so we are notified that your student is being transported to the hospital.

Sign in to Google to save your progress. Learn more
Name of person needing support: *
Person making referral: *
Required
School attending or associated with:
Contact information for person needing support: *
Date of Request: *
MM
/
DD
/
YYYY
Time
:
What are the needs at this time *
Required
If other, please explain:
Is there an existing relationship with a trusted adult within San Juan Unified?
Clear selection
If yes, please provide the name and school site:
If this is not a self referral , you may provide your name:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of San Juan Unified School District. Report Abuse
Google Forms