RH Dana Elementary Counseling Referral

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please keep in mind, this is a referral for school-related concerns.

Email *

Student's Name *

Please note, if this is an EMERGENCY and you do not have immediate access to a counselor, please speak to a trusted adult ASAP, call 911, or call 988 for the suicide prevention lifeline

Reasons for Referral *

please check all that apply

Suspected threat to others

Suspected self harm

Student seems sad/withdrawn

Student is visibly emotionally upset

Conflict mediation

Social concerns

Stress

Issue with peers

Academic concerns

Family issues

Anxiety

Depression

Social skills

Anger management

Low self esteem

Other:

Required

Summary of Concerns *

please give specifics of the problem

How urgent is this matter? *

1- the student will be seen soon 2- the student will be seen as soon as possible 3-the student will be seen immediately

Level One- The student wishes to speak with someone, but it is not an emergency or you notice something is wrong with the student

Level Two- The student wishes to speak with someone and it is an emergency (but not one of the emergencies listed for level 3) or the student is visibly emotionally upset, but they can still remain in class

Level Three-They are so visibly emotionally upset that they cannot remain in class, they are a potential harm to self, harm to others, someone is harming them, or they know of a threat on campus.

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

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Capistrano Unified School District.

Does this form look suspicious? Report

Forms