Request to See a Peer Counselor Digital Form
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IF THIS IS AN EMERGENCY, PLEASE GO TO THE COUNSELING CENTER IMMEDIATELY! THANK YOU!  
Immediate Resources:  
Central Valley Crisis & Suicide Prevention Hotline:  
1-888-506-5991

National Suicide Prevention Hotline:    call or text "988"

Crisis Text Line:    Text "HOME" to 741741

National Domestic Violence Hotline:    1-800-799-7233

Information about the Student in Need of Assistance:
Last Name *
First Name *
CUSD ID Number
Sex *
Grade Level *
Information About the Person who is Referring:
Who is Referring the Student? *
Your Name:
If you would like to remain Anonymous simply leave this section blank
Your Email:
If you would like to remain Anonymous simply leave this section blank
Why does this Individual need Assistance?
Reason for Requesting Assistance *
Please select all that apply.
Required
Additional Comments  About Situation:
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