Parent Counseling & Coaching Services (PCCS) Referral Request Form
Counseling Partners of Los Angeles (CPLA) thanks you for completing this form in effort to support the needs of your parents, students, and school community.

Here is more information about our program:
http://www.counselingpartnersofla.org/parent-counseling.html
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Email *
Name *
Phone Number *
Which CPLA School are you affiliated with? *
If your school is not listed above, what is the CPLA partner school you are affiliated with?

Type N/A if not applicable.
 *
Your Role *
Is this referral anonymous? (Our suggestion is "No." Allowing the parent to know who made the referral will demonstrate your concern and the collaboration between CPLA and the school.) *
Parent’s Full Name *
Parent’s Daytime Phone Number *
Parent’s Email Address *
Reason for Referral? *
How long has this situation been a concern? *
Are you aware of anything that is going on in the parent's life that may be causing problems? *
Have you spoken to the PARENT about possible counseling services by CPLA counselor? *
What language does the parent/legal guardian speak? *
A CPLA PCCS Counselor will respond to this within five to seven business days. 

Our business hours are Monday-Friday, 7:30AM-4PM. 

If this an emergency, please dial 911 OR visit your nearest emergency room. 

We would like to remind you that staff, students, and families can access the following hotline available 24 hours a day, 7 days a week, in English and Spanish, for free and confidential assistance:

* Suicide and Crisis Lifeline by dialing 988

Thank you!

Counseling Partners of Los Angeles (CPLA)

"Committed to healing hearts, nurturing hope and fostering bright futures for every student every day."

2016 West Washington Blvd.
Los Angeles, CA 90018

Office: (310) 459-CPLA

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A copy of your responses will be emailed to the address you provided.
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