Counselor Referral Form

This form is for teachers, staff, or students to request counseling or student support services.

If you or someone you know is experiencing challenges — academically, socially, or emotionally — please use this form to ask for help. A counselor or support staff member will review your request and follow up as soon as possible.

Staff: Use this form to refer a student for Tier 2 or Tier 3 support after all Tier 1 supports have been utilized.

Students: You can fill this out yourself if you'd like to talk to someone or need help.

If you are experiencing a crisis or need immediate help, please contact emergency services by calling 9-1-1, or reach out to a 24/7 crisis or mental health hotline.

  • 988 Suicide & Crisis Lifeline: Call or text 988

  • Placer County Adult Crisis & Intake 24 Hour Phone Line: 916-787-8860 or 1-888-886-5401

  • Nevada County Mobile Crisis Team 24/7 Phone Line: (530) 265-5811

This form is not monitored in real time. If you're in urgent need, please use one of the options above.

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