Valley Life Charter School: Parent/Guardian Referral for School Counseling Services
If you would like for your child to receive counseling services, please complete the referral. The school counselors, Darcie Young and Jessica Uribe, will contact either you or your child within five school days of receiving this referral.  If this referral is urgent or you are concerned for the safety of your student, please contact the school counselors immediately.

Thank you,
Darcie Young, Assistant Principle / Walnut Counselor Dyoung@vlcs.org
Jessica Uribe, Akers Counselor Juribe@vlcs.org
Hope Baker, Walnut  Counselor  Hbaker@vlcs.org
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Date *
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Time *
Time
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Student's Name  *
Your Name  *
What is your relationship to the student? *
Best way to contact you?
Please provide either Number or Email *
Grade Level *
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What is their teacher's name?
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Academic Reason for Referral (check all that apply) *
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Social/Emotional Reasons for Referral (check all that apply) *
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Concerns you have  *
Is your student receiving outside services?
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Concern Level: *
Would you like for the school counselor to contact you before meeting with your student? *
Preferred method of contact: Please include either a phone number or email address *
Comments: Please include any additional information
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