Counseling and Student Support Request Form

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Please complete this request for assistance form below to begin/initiate a referral.

Staff/Guardians please note: Completing this form does NOT guarantee services, but will begin/initiate an evaluation by the Tier 2/3 team and school site administrator to review and provide the most appropriate form of support for the student.

IF THIS IS AN URGENT REFERRAL, such as suicidal thoughts or concerns about safety, please notify your administrator immediately or school mental wellness team (during school hours) and/or call 9-1-1 OR The National Suicide Hotline by dialing 9-8-8

Email *

Record my email address with my response

(Parent/Guardian) Have you contacted your child's teachers? Click Not Applicable if this does not apply to you. *

Yes

Not Applicable

(Parents/Guardian) If you have contacted your child's teachers, please list the teacher or teachers below. Write NA if this does not apply to you.

Student Last Name *

Student First Name *

Student's Date of Birth *

YYYY

School Attended: *

East Whittier Middle

Other:

Grade Level *

Who is Referring? *

Referring Person's Name (Put N/A if does not apply to you): *

Referring Person's Phone Number (Put N/A if does not apply to you) *

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