25-26 Parent Form-Referral for your child to see the School Counselor
Please use this form if you think a student needs to talk to their school counselor.
Email *
Date *
MM
/
DD
/
YYYY
Person Making Referral *
Student's Name *
Teacher's Name and Room Number *
Parent/Guardian(s) Name *
Best Phone Number *
Student lives with *
Does the student receive outside counseling service? *
Check box(es) that describe your concerns *
Required
If you marked other, please type your concern below.
Does the student have any medical concerns? (i.e. mental diagnosis) *
If you marked yes,  please name diagnosis. (Diagnosis must come from a students' doctor)
Describe what you are seeing. *
Concern about safety/abuse
If you are worried about your child or a child you know that is in immediate danger to themselves or others call
911 or take them to the emergency room immediately. If you are worried about the safety or possible abuse of a child contact CPS 1-800-252-5400 or https://www.txabusehotline.org immediately.

Texas Youth Hotline
1.800.989.6884
1.800.252.5400
www.txabusehotline.org

Crisis Intervention of Houston
The Hotline: 832.416.1177
TeenTalk: 832.416.1199 (call)
TeenTalk: 281.201.4430 (text)

National Suicide Prevention Lifeline
(English) 1.800.273.8255
Crisis Text Line: Text 741741

National Suicide Prevention Lifeline
(Español) 1.888.628.9454

The Harris Center
1.833.251.7544

National Domestic Violence Hotline
1.800.799.7233
https://www.thehotline.org/2020/03/13/staying-safe-during-covid-19/
Department of Family and Protective Services Hotlines and Information Lines
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