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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
Last Name, First Initial if necessary
Primary Reason for Referral
Help with home problems
Student coping with a difficult event such as loss of a loved one, recent change/transition in the home, etc.
What are your main concerns?
What do you hope to gain from this referral?
Student to have a safe person to talk to
Specific skills training (coping skills, communication skills, etc.)
School supply assistance
Social/emotional support for student
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...?
What else would you like for me (the counselor) to know about this student/situation?
Send me a copy of my responses.
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