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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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
Reason for request
Please describe concerns
No Special Programs
Best way to contact you
Debra Piazza, School Counselor (
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This form was created inside of Norwalk-La Mirada Unified School District.