RMS Counseling Self Referral 2020-2021
Your referral matters. If this is an urgent referral such as suicidal thoughts or concerns about the safety of others, please call 9-1-1, use Text-A-Tip (562) 551-TIP2 (8472) or speak directly with a responsible adult (i.e. school staff or family member)
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Student ID #
Who are you looking for support for?
Another student at the school
If you are referring another student, what is their name?
Please share the reason you are seeking support:
Please mark all that apply
Sad, depressed or irritable mood
Problems with friends or other students
Problems with family
A recent loss (e.g. break up) or death
Challenges with teachers and other adults in school
Challenges with drugs and/or alcohol
Involvement with law enforcement such as citations, probation or previous incarceration
Housing and/or homelessness issues
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This form was created inside of El Rancho Unified School District.