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:
Additional Need(s):
Will you answer a few additional questions to help us better connect you with other free or low-cost resources?  *


Education:
Are all 4-18-year-old children in your care enrolled in school?  *
Are you or your child having any trouble with online learning?  *
Financial:
In the last 12 months, did you worry that your food would run out before you got money to buy more?  *
What is your living situation today?  *
Physical:
Do you have health insurance?  *
Have you had a medical exam within the last 12 months? (example: physical, dental, vision)  *
Have your children had a medical exam within the last 12 months? (example: physical, dental, vision)  *
Social-Emotional:
In the last 12 months, have you had difficulty managing stress, emotions, or behavior?  *
In the last 12 months, your child or children had difficulty managing stress, emotions, or behavior?  *
How often do you see or talk to people that you care about and feel close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)  *
Work/Employment:
If you haven't already, would you be interested in a program to complete your high school diploma?  *
Would you like information about job-training programs?  *
Help Seeking:
Would you like to receive assistance with any of these needs?  *
Race/Ethnicity:
American Indian or Alaskan Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Middle Eastern or Northern African
Native Hawaiian or other Pacific Islander
White
I choose not to answer
More than one-race/ethnciity
Other race, ethncicity, or origin
Gender Identity:
Gender Identity?  *
Other Gender Identity, please specify
Please correctly answer the following security question to submit this form:
What does 1+1 equal?