Requested Contact from Pupil Services Member
This form is completed to engage a pupil services staff member for support.  Referrals can be submitted by parents, by school staff or by students to request a contact from a school counselor or school psychologist This is not a form to request emergency services.  

In case of an emergency please call 911 or the county crisis line at 834-7000.  

Other Resources:  
National Suicide Prevention Lifeline
Hours: Available 24 hours.
800-273-8255

Text HOME to 741741 to connect with a Crisis Counselor
Free 24/7 support at your fingertips

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Email *
Student's Building of Attendance *
Student Last Name *
Student First Name *
Who is completing the form?
Student Grade *
Provide Brief Summary of Concern for Student - Pupil Service team member will reach out within 24 hours (exluding weekends) to student in person or via zoom *
Indicate Level of Need - Response will be within 24 hours (excluding weekends).  In case of emergency, please contact 911 or the County Crisis Line at:  834-7000, suicide hotline *
Please route concern to the following: *
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