OHS Request for Student Support Services 2019-2020
If you suspect Child Abuse or Neglect YOU MUST notify CPS at 510-259-1800.

If you are concerned about a student's social, emotional, or physical well-being, please proceed and fill out this referral for support service(s). If this is an urgent referral, please complete referral AND call SHOP 55 Wellness Center (510) 874-7152 on M-F from 8:00am - 4:00pm.

We strive to reach the student and give you a status update within one week of receiving your referral.

Note: For disciplinary actions, please refer to universal office referral form or contact OHS Administrator.

Questions? Contact below:
Luc Soriano
EBAYC Program Director - Behavioral Health Services
SHOP 55 Wellness Center
Luke@ebayc.org
(510) 874-7152
First name *
Your answer
Last name *
Your answer
Student's Date of Birth
If you don't know date of birth, please skip.
MM
/
DD
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YYYY
Student's Grade *
What 9th Grade Family OR Academy OR Program is the student enrolled in? *
Student's Gender *
Student's Race *
Your Name: *
Your answer
Referred By Role: *
Referred By Email: *
Your answer
Does student know about the referral? *
PRIMARY Reason for Referral *
SECONDARY Reason for Referral
If referral is connected to Academic Concern, please check off all that applies.
Check off all Interventions tried *
Required
To the best of your knowledge, is the student and/or the family working with anyone else on this issue? (for example, therapy, outside community provider) *
If so, who?
Your answer
Observations and concerns
Your answer
Submit
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