Student Support Services Referral 2023-2024

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Thank you for your interest in our Wellness Center. As soon as your referral is processed, we will be contacting you to schedule an appointment. The answers to the following questions will help guide us to best serve your needs. We look forward to meeting with you!

***Disclaimer: This is not a crisis response account. It's not monitored 24 hours a day, and is solely used for information purposes.***

If this is a life-threatening emergency, please call 911 or go to your nearest emergency room. If you or your child need someone to talk to during difficult times, please call or send a text to:

National Suicide Prevention Lifeline: Call 988

Crisis Text Line: Text "Home" to 741741

Trevor Lifeline: Call 1-866-488-7386

Trevor Text Line: Text "Start" to 678678

Students' First and Last Name *

Student ID

Please select which best applies to you-the person completing this form: *

I am a student

I am a parent, guardian, caregiver, or family member

I am a LBUSD staff member

Required

Has the student been notified that the referral has been made? *

Yes

I am the student.

Student's Grade Level *

9th

10th

11th

12th

How can we support you at this time? (check all that apply) *

Individual Counseling (i.e. anxiety, stress, depression, relationships)

Community Resources (i.e. food pantry, health information, housing)

Basic Needs (i.e. school supplies/toiletries)

Academic Support (i.e. tutoring, time-management)

Parent, guardian, caregiver, or family member support

Other:

Required

Is there any further information that you would like to share?

Please provide your name and best contact information *

**Confidentiality Reminder: Our services are confidential, yet as mandated reporters we are required to report if someone is being hurt, someone wants to hurt themselves, or hurt others. *

I have read and acknowledged the statement above.

Required

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