LSC - Referral Form

Student Recommendation Form

Need an appointment?

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 in evenings and on Saturdays and can meet in-person, over the phone, or virtually.

Currently enrolled LSC students from all campuses are eligible for services.

This form is NOT for emergencies. Remember, if you are facing a life-threatening emergency, please dial 911. Your safety and well-being are of utmost importance.

Thank you for contacting Communities In School of Houston.

1. Student First Name *This question is required.

2. Student Last Name *This question is required.

3. LSC ID NUMBER *This question is required.

4. PHONE # *This question is required.

5. E-MAIL: *This question is required. 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.

Academics (Attendance, Motivation/Time Management, Technology Needs, Career Planning)
Behavior (Mental Health, Self-Esteem, Family Conflict, Relationship Issues, ETC)
Social Service Needs (Food, Housing, Utility, Transportation, Medical, Childcare, Unemployment, ETC)

9. Please write a short description of how we can help.

10. How did you hear about CIS?

11. Please sign: *This question is required.

Clear

Signature of

LSC - Referral Form - FY24

Student Recommendation Form