Student and Family Support Needs Survey

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Fitzsimmons Elementary School recognizes that a variety of barriers can impede a student's success. If your student or family would benefit from additional supports, please complete the following survey.

The responses to this survey will be sent directly to our school social worker, Julie Duncan, and will be kept confidential.

The School Social Worker Association of America defines the role of a school social worker as follows: "School Social Workers are trained mental health professionals who can assist with mental health concerns, behavioral concerns, positive behavioral support, academic, and classroom support, consultation with teachers, parents, and administrators as well as provide individual and group counseling/therapy. School social workers are instrumental in furthering the mission of the schools which is to provide a setting for teaching, learning, and for the attainment of competence and confidence."

Email *

Parent/Guardian Name *

Student Name(s) *

My student did not receive services last year and I would like to enroll them in supportive services through the School Social Worker

Yes

N/A

Clear selection

My student received services last year and I would like services to continue.

Please note that if you have a consent on file, no further action is needed for your student to continue receiving support.

Yes

N/A

Clear selection

I would like my child to participate in a small group to support the following:

Anger Management

Anxiety

Bouncing back from trauma

Coping Skills

Divorce or Separation

Emotion Regulation

Executive Functioning (organizing, prioritizing, focusing, work completion)

Friendship Skills

Grief & Loss

Lunch Bunch

Other:

I would like my child to receive individual support for the following: *

Anger management

Coping with anxiety

Coping with depression

Coping with stress

Coping with a family change

Expressing feelings appropriately

Friendship and/or social skills

Divorce or separation

Grief and loss

Hyperactivity

Improve self-esteem or self-concept

Learning and utilizing coping strategies

Organizational skills, study skills, work habits

Problem solving and conflict resolution skills

Other:

Required

My family would benefit from... *

Referral to an outside mental health provider

Assistance accessing resources in the community

Participation in the holiday giving tree

No support is needed at this time.

Other:

Required

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