Berkeley High School Health Center - Counseling Referral Form

Your Full Name *

First Name Last Name
Date of Birth *
What are your pronouns?
Cell Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Grade
Preferred Language
Are you connected with any other programs/services on campus?

Student Support Services (OCI) Special Education 504 Plan Bridge RISE Other

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 Date of Birth *
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

BHS / BTA / BIS Health Center