Non Emergency Support Request Form
• If you have thoughts of suicide immediately call the Suicide Prevention Hotline at 800-273-8255. Please provide us with your name and number so we can follow up.
REMEMBER: Talk to your parents, a favorite teacher, counselor or principal—help will be provided as your well-being is our priority.
• If your concern pertains to a student's social emotional well-being, please talk with the school psychologist or counselor and fill out the support form.
• If you are concerned about your student's social emotional well-being, and have been for two weeks or more, please complete the referral form below.
If this is an emergency, please call 911 or take the student to the nearest hospital. Fill out the referral form so we are notified that your student is being transported to the hospital.
Name of person needing support:
Person making referral:
School attending or associated with:
Contact information for person needing support:
Date of Request:
What are the needs at this time
Social Emotional Concern
Food and Shelter Concern
Physical Health Concern
If other, please explain:
Is there an existing relationship with a trusted adult within San Juan Unified?
If yes, please provide the name and school site:
If this is not a self referral , you may provide your name:
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This form was created inside of San Juan Unified School District.