Mental Health Request/Solicitud de salud mental

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Please fill in this confidential form.
Por favor complete este formulario confidencial.

A staff member will reach out to you using your preferred contact method.
Un miembro del personal se comunicará con usted mediante su método de contacto preferido.

Are you or someone else feeling suicidal? Please call a suicide hot line immediately.
¿Usted o alguien más está pensando cometer suicidio? Llame a una línea directa de suicidio inmediatamente.

-California Youth Crisis Line
Línea de crisis juvenil de California
www.youthcrisisline.org ----1-800-843-5200 --- 24 Hours Bilingual

-Los Angeles County Department of Mental Health
Departamento de Salud Mental del Condado de Los Ángeles
dmh.lacounty.gov ----1-800-854-7771 --- 24 Hours Bilingual

If this is an emergency, please call 911 immediately.
Si se trata de una emergencia, llame al 911 de inmediato.

What is your name? Su Nombre *

What is your contact phone number?/Número de Teléfono *

Please list your email/Correro electronico *

If you need assistance filling in the form, or have concerns or questions please call the Palmdale School District Mental Health Department 661-789-6783/ Si necesita ayuda para completar el formulario o tiene preguntas adicionales, llame al Departamento de Salud Mental del Distrito Escolar de Palmdale 661-789-6783

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