Parent/Staff Referral to the Ella Elementary School Counselor 2026-2027

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Email *

Name of Person Making the Referral*

First name and last name of student being referred*

Name and grade of the student's teacher*

Student's Gender*

Female

Male

Other

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Is it OK to tell student you referred them?*

Yes

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Are the parents/guardians aware of their student being referred?*

Yes

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What challenges do you see the student faces?*

Academics

Access to basic resources (e.g. food, shelter, health care etc.)

Alcohol and/or other drugs (Vaping)

Anxiety

Attendance

Body image

Bullying

Depression

Eating problems

Family relationships (e.g. parent-child conflict)

Gender identity and/or sexual orientation

Grief and loss

Lack of/unhealthy coping skills

Peer/friend relationships

Race and/or ethnic identity

Other:

Thank you for the referral. Mr. Jack Yang will contact you in 1-2 business days.

If you need to contact me please email me at jacky@mjusd.k12.ca.us or call me at (530) 741-6124 ext. 4417

YYYY

A copy of your responses will be emailed to the address you provided.

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