EOPA Mental Health Counseling Request Form 2021-2022
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)
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Student ID #
Grade *
Student Cell Phone # *
Who are you looking for support for? *
If you are referring another student, what is their name?  
Please share the reason you are seeking support:
Please mark all that apply
Clear form
Never submit passwords through Google Forms.
This form was created inside of El Rancho Unified School District. Report Abuse