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?  *
Preferred email to contact you?:  *
Zip Code:  *
What language are you most comfortable speaking?:  *


Student (I) Details:
What is your relationship to student/client?:  *
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:  *
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:
 *