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LSC - Referral Form - FY22

Student Recommendation Form

Need assistance?

Fill out this form and a CIS team member will respond to your request within two business days. 

While CIS hours are Monday through Friday 8:00 am - 4:00 pm, we work with students to make appointments that work for them. We offer appointments on evenings and Saturdays and can meet in-person, over the phone, or virtually. 

Students from all campuses are eligible for services.
This form is NOT for emergencies. In case of an emergency, please call 911.

Thank you for contacting Communities In School of Houston.
This question requires a valid email address.
8. Let us know what type of help is being requested. Please be aware that you may be served at school or referred to an outside agency for services. Feel free to select multiple boxes. *This question is required.
11. Please sign:  *This question is required.
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