Counseling Referral Form

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Counseling Referral Form - LAMS

Please complete the form below to notify the campus counselors and social worker of your request for contact. All submissions will be reviewed during school hours, Monday-Friday 7:30 - 4:30. A Counselor or Social Worker will initiate contact as soon they are available.

Email *

Student's FULL name: *

Student's ID:

Name of person completing this form & relation to student (type "SELF" if you are a student, self-referring): *

Reason(s) for Referral: *

Preferred Method of Contact: *

Phone Call

Office Visit

Other:

Contact Information (you are welcome to provide multiple forms of contact): *

Submit

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