El Rancho High School Mental Health Counseling Request Form 2020-2021

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

* IF THIS IS AN URGENT REFERRAL, SUCH AS SUICIDAL THOUGHTS OR CONCERNS ABOUT SAFETY, PLEASE CALL 9-1-1 OR THE NATIONAL SUICIDE HOTLINE AT 1 (800) 273-8255 (TALK) IMMEDIATELY*

**PLEASE NOTE THE PARENTS/GUARDIANS WILL BE CONTACTED FIRST TO RECEIVE PERMISSION TO SPEAK DIRECTLY WITH STUDENTS**

Email *

Student's Full Name *

Student ID Number (If Available)

Grade *

Best Contact Phone Number For Person Making This Referral *

Who are you referring? *

Myself

Another El Rancho High School Student

My Child

Name of the Person Making The Referral (Optional)

Please Describe Your Primary Concern And Your Reason For The Referral (Be Specific): *

Please Mark All That Apply (optional)

Sad, depressed or irritable mood

Withdrawn/isolates self

Problems with friends or other students

Problems with family

A recent loss (e.g. break up) or death

Angers easily

Aggressive behavior

Bullying (Target/Aggressor)

Challenges with teachers and other adults in school

Challenges with drugs and/or alcohol

Involvement with law enforcement such as citations, probation or previous incarceration

Dating/partner issue

Need information about sexual health

Gender/sexual identity

Housing and/or homelessness issues

Clear form

Never submit passwords through Google Forms.

This form was created inside of El Rancho Unified School District. Report Abuse

Forms