EmailMeForm
SCHOOL BASED REFERRAL
Amanecer Community Counseling Service
Questions/Concerns: Contact School-Based Program Manager Cynthia Godina at 213-407-4332.
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Student’s Name
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First
Last
Today's Date
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MM
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DD
/
YYYY
Date of Birth
*
MM
/
DD
/
YYYY
Grade
*
School
*
Please select
10th Street Elementary School
Abraham Lincoln High School
Betty Plasencia Elementary School
Esperanza Elementary School
Francisco Bravo Senior High Medical Magnet
John Liechty Middle School
Leo Politi Elementary School
MacArthur Park Elementary Visual and Performing Arts
Miguel Contreras Learning Complex- Academic Leadership Community
Miguel Contreras Learning Complex- School of Business & Tourism
Miguel Contreras Learning Complex- School of Global Studies
Miguel Contreras Learning Complex- School of Social Justice
Nava College Preparatory Academy
RFK UCLA Community School
Virgil Middle School
Young Oak Kim Academy
UAM(New Comer/Arrival/Unaccompanied Minor)
*
YES
NO
Country of Origin
*
Current Caregiver’s Name
*
First
Last
(Parent, family member, legal guardian, foster parent, placement provider, etc.)
Home Phone
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Cell Phone
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Child's Preferred Language
*
English
Spanish
Other
Parent/Caregiver's Preferred Language
*
English
Spanish
Other
Other Language
Student’s Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Referring Person
*
First
Last
Referring Person's Contact Information
*
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-
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Referring Person's Relationship To Child
*
Referring Person's Email
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