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Request for Assistance from Parent/Guardian
This form can be used to request services for a student, such as school supply/uniform needs, academic concerns, home problems, social/emotional concerns, and behavioral interventions at school. If you do not receive a response within 3 school days, please send an email to
Email address *
Student Name *
Your answer
Grade *
Child's Teacher *
Last Name, First Initial if necessary
Your answer
Primary Reason for Referral *
What are your main concerns? *
Your answer
What do you hope to gain from this referral? *
When and how was the teacher contacted? (Date and method of communication) *
What date did you speak to the teacher about this concern? How did you speak with the teacher-note home, phone, conference...?
Your answer
What else would you like for me (the counselor) to know about this student/situation? *
Your answer
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