2025-2026 Loma Alta Counseling Center Referral

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Complete this form to refer a student to the Counseling Center. Discipline issues should be sent to administrators.

Please do not send a student to the Counseling Center without completing this form.

Email *

Who is submitting this referral? *

Teacher/Admin/Staff

Student

Parent

Other

Student First Name *

Student Last Name *

Grade *

6th

7th

8th

How soon do you need to be seen?

I want to talk to you about something, and I'm hoping to see you sometime this week.

Not an emergency, just something I wanted to talk about as soon as possible.

Urgent (meaning you are worried about the safety of yourself or others)? (Teachers, if yes: buzz office or walk them to office, must be left with an adult)

Unless requested by student. put first available. Counselor/ Social Worker: *

First Available

Mr. Pena (Counselor)

Ms. Buckaloo (Counselor)

Ms. Amanda Rodriguez (Counselor)

Ms. Stephanie Rodriguez (Social Worker, only @LOMA 3x a week)

Reason for referral or additional information (if student does not wish to disclose please put N/A) *

Send me a copy of my responses.

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