EM School Counseling Referral

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Hello!

Please use this form to refer your student to school based counseling services. Please allow 2-3 business days for your request to be processed. Once I receive this form, I may be in contact with you regarding potential services.

This is not an emergency response service. In the event of a life threatening emergency, please call :

9-1-1
9-8-8 (Suicide and Crisis Lifeline)
1-800-273-8255 (National Suicide Hotline)

Please keep in mind that:

School Counseling is brief and solution focused, typically lasting 1 to 8 sessions.
Parent permission is required for all counseling services.
Not all students referred will receive school-based services.
If ongoing services are needed, you will be contacted for a Family Center or Care Solace (outside services) referral.
If you would like to continue counseling services beyond school-based counseling services (6-8 sessions) please contact me.

If you have any questions or concerns, please do not hesitate to contact me. I can be reached at xitlaliavila@ccusd.org

Thank you,

Ms. Liu and Ms. Barot

El Marino School Counselors

Email *

Student First and Last Name *

Student Grade Level *

Which Language Program is your student apart of?

Japanese Immersion Program

Spanish Immersion Program

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Please indicate the urgency of this referral (choose one): *

Crisis - immediate response (please contact counselor and/or administrator)

Concerning - as soon as possible

Stable - at earliest convenience

Required

Relationship to Student: *

Teacher/Staff

Parent/Guardian

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