Student Support & Health Services Department Connect Center Referral Form
SCUSD/s gateway for connecting students and families with support services

If you are completing this referral for LBGTQ+ Support Services please complete the LGBTQ+ Support Services Referral found at https://linktr.ee/scusd_lgbtq

Please DO NOT use this form to request Suicide Risk Assessment.
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Email *
Students Name (First & Last) *
Student's School *
Student's grade *
Is student aware of this referral? *
Required
Parent/Guardian Name *
Is parent aware of this referral? *
Required
Parent Contact Number *
Primary Language *
Area of Concern *
Required
Please provide a more detailed description of these issues and any other concerns. *
Are you Aware of any other staff and/or service providers that are involved with this student/family? If so, please check all that apply:
Does the student and/or family have health insurance?

(If no, please select Lack of Health Insurance Coverage as an area of concern above.)
 *
Type of Health Insurance *
Describe Coverage Below *
Required
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