Referral for School Counseling Services

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Please complete the form below if you would like to request time to speak with your School Counselor. He/She will reach out within one (1) business day of receiving the referral.

Please note: This is for non-crisis needs.

Should you or your child experience a mental health crisis please contact any of the following:

Mobile Crisis, Integrated Family Services Crisis Line: 1-866-437-1821
RHA Behavioral Health Crisis Management Services: 1-844-709-4097
Coastal Horizons Center, Inc. - Crisis Line: 1-800-672-2903
Coastal Horizons Center, Inc - Clinica Latina: 910-769-1201
National Suicide Prevention Lifeline - Crisis Line: 1-800-273-TALK (8255)
National Suicide Prevention Lifeline - Crisis Text Line: Text HOME to 741741

Email *

Student Name (Last, first) *

Person Making Referral *

Parent/Guardian

Student (Self-Referral)

Name of Parent/Guardian Making the Referral

Select Format *

In-Person

Virtual - Google Meet/Phone Call (An adult must be present at home during the session.)

I am interested in scheduling, but neither option works. (The school will make contact with you.)

Response/Service Requested *

Academic

Behavioral/Social Emotional

College/Scholarships

General Information

Unsure

Other:

Please specify preferred time(s). *

8:30-10:00

10:00-11:30

11:30-1:00

1:00-2:30

Required

Submit

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