Referral for School Based Mental Health
*If you are having a mental health emergency, please call 911 or go to your nearest Emergency Room*
This form is intended for parents/caregivers to complete for their student(s) or for a student to complete on their own. These referrals are accepted during the school year (August-June), not during summer. Counseling services will be provided at the school sites, however Hazel Health can also be done at home. Any referrals made in the summer will be assigned at the beginning of the school year. Confidentiality Notice: This referral form is for the sole use of the intended recipient Dori Rosental Saporito (saporito_d@sgusd.k12.ca.us) and may contain confidential and privileged information.
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Email *
Who is submitting this referral? Name and relationship to student: *
Student Name *
Student Date of Birth  and Age  *
MM
/
DD
/
YYYY
School Attending *
Chosen Name:                                   Pronouns:
Parent Name: *
Parent Phone Number 

 *
Student Phone Number

Parent Preferred Language: *
Student Preferred Language: *
Do you have Medi-Cal Insurance: *
If yes, what is your student's Medi-Cal #:
 (# will be in this format: 91234567A2 9180)
Referral Details, Please Check all that apply: *
Required
Briefly Describe Concerns: *
Anything else you need to share?
Submit
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