LAUSD Student & Family Wellness Self-Referral
Thank you for contacting LAUSD Student Health and Human Services.
You are taking the first step towards a path to student and family wellness.

If you are experiencing a psychiatric or health emergency, please call 911.
If you are experiencing a mental health crisis or need immediate social-emotional support,
please call the Los Angeles County Department of Mental Health Help Line at 1-800-854-7771.
For non-emergencies and other services, you can also call 211 or visit www.211la.org after completing the questions below.
You can also call us at (213) 241-3840 Monday through Friday from 8am-5pm or email ask-shhs@lausd.net
Contact Information:
First Name:  *
Last Name:  *
Best day time phone number to contact you?  *
Ok to call or text you at this number?:
Phone Number Type?  *
Preferred email to contact you?:  *
Zip Code:  *
What language are you most comfortable speaking?:  *
Student Details:
Student First Name:
Student Last Name:
Student ID:
How can we help you?
Basic Needs (for example, food, clothing, transportation, baby supply needs, health insurance enrollment):
Mental Health Support (for example, stress, anxiety, depression, need someone to talk to):
Immunizations:
Medical exams or eye exams:
Student Enrollment or Engagement/Attendance:
Student in foster care, experiencing homelessness, or involved in juvenile justice:
Other:
Please correctly answer the following security question to submit this form:
What does 0+0 equal?