Social-Emotional / Behavioral Support Form

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Please fill out this form if you would like to receive a phone call to discuss social emotional concerns. If you need immediate mental health assistance, please call:
(Por favor complete esta forma si le gustaria recibir una llamada por telefono para hablar sobre preocupaciones sociales emocionales o de comportamiento. Si necesita ayuda inmediata de salud mental, por favor llame):

National Suicide Prevention Hotline: 1-800-273-8255
Crisis Text Line: Text HOME to 741741 in the United States
Merced County Mental Health Services: (209) 381-6879
Nine-Line Crisis Counseling (24 hours): 1-800-999-9999
Sierra Vista Child & Family Services: (209) 205-1058
Marie Green Inpatient Psychiatric Center (209) 381-6879

Please identify your role in AESD (Por favor indique su papel en AESD) *

Student / Estudiante

Parent / Padre

If you are a parent, please list the name of the child/children in need of support: (Si es padre, indique el nombre del niño o niños que necesitan apoyo)

Please identify the AESD school that you attend, or that your child attends (Por favor indique la escuela en AESD que usted asiste o que su hijo asiste) *

Aileen Colburn

Bellevue

Elmer Wood

Juniper

Mitchell K-6

Mitchell Senior / Atwater Senior Academy

Peggy Heller

Shaffer

Thomas Olaeta

Preschool

Please list your name (Por favor escriba su nombre) *

What is the reason for your request to hear from a school psychologist? (Cual es la razon para su solicitud de hablar con un psicologo escolar?) *

Please list the best phone number where you can be reached (Por favor escriba el mejor numero de telefono donde pueda ser contactado) *

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