2021-22 CPLA Counseling Referral Request Form
Counseling Partners of Los Angeles thanks you for completing this form in effort to support the needs of the students and school community.
Sign in to Google to save your progress. Learn more
Email *
Your full name? *
Your daytime phone contact number? *
Date submitting this referral *
MM
/
DD
/
YYYY
Which CPLA school are you affiliated with? *
I am a (blank) filling out this form: *
Required
Full name of the STUDENT being referred for counseling services: *
What is the student's grade level?
*FACULTY/STAFF ONLY* Is this referral anonymous? (Our suggestion is "No." Allowing the student and family know who made the referral will demonstrate your concern and the collaboration between CPLA and the school.) *
What is the best PHONE NUMBER for our counselor to reach the student and his/her family? *
What is the best EMAIL ADDRESS for our counselor to reach the STUDENT and their family about this referral? *
Reason for Referral: *
Required
How long has this situation been a concern? *
Required
Are you aware of anything that is going on in the student's life that may be causing problems? *
*FACULTY/STAFF ONLY* Have you spoken to the student's PARENT/S about possible counseling services provided by CPLA counselor? Write N/A if not applicable. *
*STUDENT ONLY* Have you spoken to your parent/s or faculty/staff about possible counseling services provided by CPLA counselor? Write N/A if not applicable. *
*FACULTY/STAFF & PARENT ONLY* Have you spoken to the STUDENT about possible counseling services by CPLA counselor? Write N/A if not applicable. *
What language(s) do the parents/legal guardians speak? *
A CPLA Counselor will respond to this within two business days. Our business hours are Monday-Friday, 7:30AM-4PM. If this an emergency, please dial 911 OR visit your nearest emergency room. We would like to remind you that staff, students, and families can access the following hotlines via voice or text: *24-Hour Crisis Hotline (800) 273-TALK (8255); *TeenLine (310) 855-HOPE (4673) or Text “TEEN” to 839863, both available 6-9pm; *Crisis Text Line by texting 'HOME' to 741741, available 24/7. Thank you! Counseling Partners of Los Angeles (CPLA) "Committed to healing hearts, nurturing hope and fostering bright futures for every student every day." 2016 West Washington Blvd. Los Angeles, CA 90018 Office: (310) 459-CPLA http://counselingpartnersofla.org *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Counseling Partners of Los Angeles. Report Abuse