Benton Middle School Counseling STAFF or PARENT/GUARDIAN Request
Please complete this form to refer your child/student to Mrs. Piazza, the Counselor.

Note for Educators: All educators are mandated reporters and must immediately report any suspected child abuse or neglect to Child Protective Services.

Note: Below are resources available should you find yourself or someone else in a situation where immediate mental health services are needed.

National Suicide Prevention Hotline --- 1.800.273.8255
Central Crisis & Suicide Prevention Hotline --- 1.888.506.5991
Crisis Text Line --- Text HOME to 741741


Please understand that confidentiality cannot be guaranteed in virtual meetings. The counselor will make every effort to ensure a confidential conversation, and as always, if there is a concern that you may harm yourself or others, or that someone is causing you significant harm the appropriate persons will be contacted.
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Email *
Today's Date: *
MM
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DD
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YYYY
My child/student attends *
Who Is Making This Referral? *
What is your first and last name? *
First Name of Child/Student *
Last Name of Child/Student *
Grade *
Reason for request *
Please describe concerns *
Special Programs *
Required
email address *
Telephone Number *
Best way to contact you *
Required
Debra Piazza, School Counselor (dpiazza@nlmusd.org)
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