EOPA Mental Health Counseling Request Form 2021-2022

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

Your referral matters. If this is an urgent situation such as suicidal thoughts or concerns about the safety of others, please call 9-1-1 or speak directly with a responsible adult (i.e. school staff or family member)

Email *

Full Name *

Student ID #

Grade *

Student Cell Phone # *

Who are you looking for support for? *

Myself

Another student at the school

If you are referring another student, what is their name?

Please share the reason you are seeking support:

Please mark all that apply

Sad, depressed or irritable mood

Withdrawn/isolates self

Problems with friends or other students

Problems with family

A recent loss (e.g. break up) or death

Angers easily

Aggressive behavior

Bullying (Target/Aggressor)

Challenges with teachers and other adults in school

Challenges with drugs and/or alcohol

Involvement with law enforcement such as citations, probation or previous incarceration

Dating/partner issue

Need information about sexual health

Gender/sexual identity

Housing and/or homelessness issues

Clear form

Never submit passwords through Google Forms.

This form was created inside of El Rancho Unified School District. Report Abuse

Forms