Staff Counseling Referral Form

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Requests will be sent via e-mail to Mrs. Clark, Monday - Friday, 8 AM - 3 PM.
If a student is in crisis (engaging in self-harm, expressing suicidal or homicidal thoughts) please contact a school counselor, school psychologist, or administrator by phone IMMEDIATELY.
Emergency situations call 9-1-1.

Students can access the following numbers for further immediate support during non-office hours:

Crisis Text Line: Text "LA" to 741741
Department of Mental Health: 1-800-854-7771
National Suicide Hotline: 1-800-273-8255
Trevor Project Lifeline (Available 24/7; Confidential Suicide Hotline for LGBT Youth): 866-488-7386
Emergency Situation: 911

Email *

Referring Teacher *

Student Name (First/Last) *

Grade *

6th

7th

8th

Reason for Referral *

Difficulty reaching student

Online SEL Resources

Online Academic Resources

Concerned for a student's mental/physical.emotional well being

Other:

Required

Immediacy of referral

Must Speak to Student Right Away!

Within a Few Days

Within the Next Week

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Any additional Information/Comments

A copy of your responses will be emailed to the address you provided.

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