Berkeley High School Health Center - Counseling Referral Form

BHS / BTA / BIS Health Center

Mental Health Counseling Services
Welcome to our Health Center's e-portal for mental health counseling referrals.

In the State of California, minors 12 and older can consent to their own mental health treatment and counseling services, under certain circumstances.

Our services are available to all BHS, BTA, and BIS students, and our services are free and confidential. There are a few exceptions to confidentiality related to safety, and a counselor will explain these exceptions to you. A counselor will also discuss with you any safety-related information that you share in this form.

Please answer the following questions. After you submit this form, a counselor will contact you to discuss next steps.

Who is this referral for? *

Myself Someone else

What brings you to counseling now?
What do you hope to get out of counseling?
Do you have any concerns about your safety right now? If so, please explain.

We strongly recommend that you discuss a potential referral with a student prior to submitting a referral on their behalf, as this often increases receptivity and engagement.
Student's Full Name *

First Name Last Name
Student's Pronouns? *
Student's Date of Birth *
Grade
Student's Cell Phone Number (Strongly Preferred)
Please enter a valid phone number.
Student's Email *
example@example.com
Your Full Name (Referral Source) *

First Name Last Name
Your Relation to Student *
Your Phone Number *
Please enter a valid phone number.
Your Email *
example@example.com
Is this student connected with any other programs/services on campus?

Student Support Services (OCI) Special Education 504 Plan Bridge RISE Other
Have you spoken to this student about this counseling referral? *

Yes No

Please explain why you have referred this student for counseling services. *
How do you hope this student will benefit from counseling services?
Do you have any concerns about this student's safety? If so, please explain.
Should be Empty: