School Counseling Referral Form

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Students, teachers, or parents/guardians can use this form to refer a student for school counseling regarding social/emotional concerns. Responses go directly to the Pivot school counseling team. If you are experiencing a mental health crisis or emergency, do not fill out this form - call 911 or go to your nearest emergency room.

To speak to a crisis counselor, call or text the National Suicide Prevention Lifeline at 988.

Email *

Name of the student being referred *

Which school site is the student enrolled at? *

Pivot North Bay (Santa Rosa)

Pivot Riverside (Corona)

Pivot North Valley (Chico)

Pivot San Diego (San Marcos)

What Grade is the student in? *

High School (Grades 9-12+)

Middle School (Grades 6-8)

Elementary School (Grades K-5)

I am *

the Student

the Parent/Guardian

a Pivot staff member

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