Lawrence E. Jones Middle School-Based Mental Health Support: Request for Appointment

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Please use this form to request an appointment with CRPUSD school-based mental health support. Appointments will be conducted either via video conferencing or by phone. Please note that these remote appointments are not intended to replace the student’s medical care or services provided by an outside mental health care provider. These services are intended to support students in identifying and managing difficult feelings, and in developing effective coping strategies during these challenging times. A school-based professional will contact you within two school days (Monday – Friday).

Important: This is not a crisis line. For crisis support dial 911 immediately, or one of the following resources listed below:

• Sonoma County crisis stabilization unit (707) 576-8181
• Sonoma County Suicide Prevention Hotline: (855) 587-6373

For additional wellness or mental health support, check out the CRPUSD External Distance Learning Resources at https://bit.ly/CRPUSHELPS

If you have questions about classes or academics, please contact your school’s counselor or administrators.

If you have concerns about a friend, remember you can still use the STOPit app on your phone at any time to report an issue anonymously. School administrators check STOPit app reports every day.

(Para español, haga clic aquí: https://forms.gle/6PcEjVMXJs4MdCp59)

Who are you? *

Parent/Guardian

Student

Required

Your Name: *

Student's Last Name: *

Student's First Name: *

Student ID Number (if available):

Please indicate some of the concerns you would like support around (mark all that apply): *

Feelings of sadness and depression

Feelings of fear, nervousness, or anxiety

Feeling isolated or lonely

Feelings of anger or frustration

Financial concerns (income, food, or housing scarcity)

Anxiety about grades or academics

Family problems

Help finding mental health support/other resources

Other:

Required

Are you currently receiving, or have you received in the past, mental health services or support from a staff member at your school?: *

Yes

I don't know

If yes, please indicate who provided the support:

A CRPUSD school-based mental health professional will contact you to arrange for an appointment time. How would you like to be contacted?: *

Phone

Please provide your phone number and/or email address below so we can contact you to set up an appointment time: *

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