Don Juan Avila Elementary School Counseling Student Referral Form 2023-2024 School Year
This referral form is for Don Juan Avila Elementary School students who would like to meet with the school counselor, Ms. Gomez. Ms. Gomez will need to contact your parent to get permission for counseling. Please let them know you filled out this form to speak with me.

NOTE: If this is an EMERGENCY and you do not have immediate access to a counselor, please speak to a trusted adult ASAP, Call 911, or call the Suicide Prevention Lifeline 1 800-273-8255 or text 988.
Sign in to Google to save your progress. Learn more
Please complete the following form: 
Your First and Last Name *
Today's Date
MM
/
DD
/
YYYY
Grade Level *
Who is your teacher?
What is the size of your problem?
Captionless Image
Clear selection
Reason for Referral (Select all that apply) *
Please tell me a little more about the problem or concern: *
Do you understand what confidentiality means? *
Captionless Image
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Capistrano Unified School District. Report Abuse
Google Forms