CARE Team Resource Request Form -              ECHS 2025-2026
Instructions: Please use this form to request support for a student.  

The CARE Team meets weekly to reviews requests. We'll get back to you with next steps within 2 weeks.

Please complete this form with as much detail as possible.

IF YOU ARE CONCERNED a student is at RISK OF HARM to their self or others, please start by contacting one of the following - then complete this form:

1. In case of a life-threatening emergency, please call 911.

2. During the workday, please contact the following people and share your safety concern:
   
       *ECHS Administration: -- Call ECHS Front Office: 510-231-1437

                                                   *Nancy Flocchini, AP (Last Names A-Ga)
                                                   *Monica Ng, AP (Last Names: Ge-N)
                                                   *Kate Bloomer, AP (Last Names O-Z)

3. Outside of regular business hours, contact one of the following for support & advice:

       *Contra Costa County Mobile Crisis Response Team: (877) 441-1089 (24 hr support- by phone)
       *California Youth Crisis Line: 800-843-5200 (24 hour crisis support)
       *Contra Costa Crisis Center - 800-833-2900 (24 hour crisis support)

NOTE: Even if you have called due to a safety issue, please complete this form so we can follow-up.

Sign in to Google to save your progress. Learn more
Email *
Name of Person Requesting Support for the Student *
Student's Last Name: *
Student's First Name: *
4. Student's WCCUSD ID # 
5. Student's grade level
Clear selection
6. CONCERNS - Please check all concerns that might apply for the student: *
Required
7. Background Info - Please provide information about what concerns you have for the student, and any other background information you think would be good for us to know:  *
8. Previous Supports - Please let us know what has already been tried to support the student (either in the classroom, at home, or in the community): *
9. Others Involved - Who have you discussed this CARE Resource Request with (ie: who have you talked with about your concerns or hopes for this student)? (check all that apply)  *
Required
10. Phone Number:  If you are NOT a WCCUSD staff member, please provide your phone number here.
11. JMP Request - If you are specifically requesting JMP (James Morehouse Project) individual counseling or a JMP group, please check below. If you know what group you are requesting, please write it in the response to the next question.
12. JMP Group Info
The JMP is planning to offer the following groups:
  • Anxiety Group
  • Chicos Latinos (Spanish-speaking boys)
  • Gender Magic (gender expansive & questioning)
  • Grief Group
  • Monarcas (Spanish-speaking girls)
  • Poetic'ly Speakin' (creative writing for African American students)
  • Rinconcito Latino (Spanish-speaking, immigrant students)
  • Skittles (LGBTQ+ students of color)
  • TUPE (education & advocacy re: substance use)
  • Water (young womxn of color)
  • Young Men's Groups
  • Young Women's Groups


***THE GROUP REQUEST FORM WILL OPEN A LINK IN A NEW TAB. MAKE SURE YOU FINISH SUBMITTING THIS FORM!!!***

If there is interest in joining one of these groups please complete this separate JMP group request form. 
On the group form, please list your top 3 groups. The JMP will check to determine that the student is in the best fitting group, and that student is not enrolled in more than one group at a time (in most cases). 

Groups start at various times throughout the year. Requesting the group does not guarantee that the student will be able to participate, but will do our best!
13. Comments - Thank you for answering these questions. Do you have any other comments at this time?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of West Contra Costa Unified School District.

Does this form look suspicious? Report

Google Forms