North Star - Counseling Request
Mono County Office of Education (MCOE) and Mono County Behavioral Health (MCBH) collaboratively provide counseling and mental wellbeing support for students and their families. This private request form allows you to begin the referral process to the MCOE Mental Health Team and/or North Star Counseling. Your response will be reviewed in our weekly Case Management + North Star Care Coordination Meeting and then we will work with parents to complete permission slips. Students may be seen via individual counseling or social-emotional group sessions. Thank you for your patience.
Sign in to Google to save your progress. Learn more
Email *
What is the source of this referral? *
Student Name: *
First and Last
Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian Name: *
First and Last
To the best of your knowledge, is this person the *legal* parent/guardian?
Clear selection
Parent/Guardian Phone Number: *
Parent/Guardian Email: *
Client Address:
School: *
Grade: *
What is the reason for your referral? Please be as specific and descriptive as possible to help our Mental Health Team coordinate care. *
What are some strengths that this student has? *
What is the student's preferred language? *
To the best of your knowledge, is this student already receiving mental health services from any local or remote provider? *
Is there any other information we should know to better support this student? *
Date of Referral *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Mono County Office of Education.

Does this form look suspicious? Report

Google Forms