LAUSD SHHS Self-Referral Online Form
You are taking the first step towards a path to student and family wellness.
Our regular hours are Monday - Friday from 8am-4:30pm.
If you are experiencing a psychiatrict 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.
Contact Information:
First Name:
*
Last Name:
*
Best phone number to contact you?
*
Ok to call or text you at this number?:
Phone Number Type?
Home
Cell Phone
Business
*
Preferred email to contact you?:
*
Zip Code:
*
What language are you most comfortable speaking?:
English
American Sign Language
Arabic
Armenian
Burmese
Cambodian\Khmer
Cantonese\China
Choctaw\AmerInd
Creole
Czech
Danish
Dutch
Farsi (Persian)
French
German
Greek
Hebrew
Hindi
Hmong
Hungarian
Ibo
IlocanoFilipino
Indonesian
Italian
Japanese
Javanese
Kanjobal
Khmu
Korean
Kurdish
Lahu
Lao
Latvian
Lithuanian
Malay
Mandarin \China
Marshallese
Melanesian
Mien(Yao)
N/A
Norwegian
Other - NotListed
Polish
Portuguese
Punjabi
Romanian
Russian
SINHALESE
Samoan
Serbo-Croatian
Spanish
Swahili
Swedish
Taiwanese\China
Thai
Tigrinya
Toishanese\Chna
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
Visayan
Yiddish
Yoruba
*
Student (I) Details:
What is your relationship to student/client?:
Self
Mother
Father
Step-Parent
Guardian
Foster Care Parent
Grandparent
Staff
*
Student First Name:
Student Last Name:
Student ID:
Student (II) Details:
Student First Name (II):
Student Last Name (II):
Student ID II):
How can we help you?
Working Computing Device (Computer, Laptop)/internet:
Adult Continued Education:
Attendance:
Connection: Online Classes; Platforms:
Employment/Job/Career:
School Enrollment:
Food:
Housing Assistance:
Health Insurance Enrollment (Adult):
Health Insurance Enrollment (Child):
Medical/Dental Care (Adult):
Medical/Dental Care (Child):
Mental Health Needs:
Service Method:
In-Person
Virtual/Teletherapy
*
Other, Please Describe:
Would you like to be screened for additional free or low cost resources? If so, please check this box and a survey will be sent via email
Please match the correct response to the image displayed below to submit:
Chess
Rocket
School
Star
Tooth
Trophy
*