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Parent/Guardian Request for Counseling-Cabrillo
Please fill out the form below to arrange a meeting with CMS School Counselor, Alyssa Knowles.
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* Indicates required question
Email
*
Record my email address with my response
Student Name (First and Last)
*
Your answer
Parent/Guardian Name (First and Last)
*
Your answer
Parent/Guardian Cell Number or Best Number
*
Your answer
*
MM
/
DD
/
YYYY
*
Time
:
AM
PM
Parent/Guardian Email
*
Your answer
Academic Reason for Referral (Check all that apply)
*
Attendance
Underachievement
Study Skills
Organization
Homework
Schedule Change
Elective Options
High School Transition Information
Summer School Information
School Of Choice Information
Behavior Concerns
Social Concerns
Other:
Required
Social /Emotional Reason for Referral (Check all that apply)
*
Anger Management
Social Skills/Friends
Social Media
Negative Attitude
Withdrawn/shy
Confidence / Self-Esteem
Anxiety
Unccoperative/Defiant
Family Issues
Adjustment
Grief/Loss
Other:
Required
What time of the day works best for you to meet?
*
Mornings
Afternoons
Anytime of the day
Other:
Are you open to a Zoom Meeting?
*
Yes
No
I'd prefer a phone meeting
What is the best way to get in contact with you:
*
Email
Cell Phone
Home Phone
Work Phone
Other:
Thank you. I will be in contact with you shortly.
Emergency Resources:
Suicide Hotline: 1-866-998-8255
VCBH: Crisis Line: 1-800-273-8255
VPD: 1-805-339-4400 EMERGENCY: 911
Child Protective Services: 1-805-654-3200
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