CHS Parents and Guardians - Student Referral to Mrs. Strong, PSW (Psychiatric Social Worker) Services

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Please complete this form if you or your teen is in need of social support or mental health services. You will get a response within 2 school days from Mrs. Strong. If you are experiencing a psychiatric or health emergency, please call 911. If you are experiencing a mental health crisis and need immediate help, the Los Angeles County Department of Mental Health at 1-800-854-7771, or the National Suicide Prevention Hotline at 1-800-273-8255.

Name of Parent (Last name, First name) *

Email address

Name of Student (Last name, First name) *

Date of Birth *

YYYY

Student Grade Level *

Current Home Address (# Street Name; City; Zip Code) *

Phone number (Enter as xxx-xxx-xxxx) *

Best Time to Call *

8:00-10:00am

10:00am-12:00pm

12:00-2:00pm

2:00-4:00pm

Select from the following options: *

I would like to talk to someone as soon as possible about my child and my concerns.

I would like to talk to someone within the next few days. about my child and my concerns.

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