Parent/Guardian Request For Support
School Wellness Centers are a place where students and families can find support for many issues that may present while your child is attending school.  During the Pandemic we also understand that students and parents/guardians may benefit from additional resource.  Wellness staff are well versed in supports throughout the community and can help connect you based on your needs.  

To access support please complete the form below, this referral will be reviewed and teamed with your students counselor and you will be contacted.  

If your child is experiencing a CRISIS or THOUGHTS OF SUICIDE CONTACT THE SUICIDE HOTLINE @ 1-800-273-8211 OR TEXT 741741.
Sign in to Google to save your progress. Learn more
Email *
School *
Student Name - Last, First *
Parent/Guardian Name - Last, First *
Parent/Guardian - Best contact phone number or email *
What is the best time and day for someone to contact you? (Monday-Friday 8am-4pm). *
Grade Of Student *
Gender identity of your student: *
Support being requested *
If your request for support is for mental health, what is the topic area (optional)?
Does your student, or family, fall into any of these cohort populations: *
Clear form
Never submit passwords through Google Forms.
This form was created inside of RJUHSD. Report Abuse