ASTI'S REQUEST FOR ASSISTANCE

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Students and family members can request help for a student by using this form. ASTI staff members should use Aeries to make this kind of request.

Please note that options for group counseling may not be available.

Name of Student *

Grade Level: *

What is your name? *

I am requesting support in the following area(s): *

Academics

Behavior

Social-Emotional Health

Attendance

Other:

Required

Why are you making this request? Check all that apply to the student. *

Lack of work completion

Inconsistent School attendance

Withdrawn/Isolated from peers

Anxious/Worried

Basic Needs are not being met (food, shelter,clothing, hygiene)

Health Issues (vision, dental, stomach, headaches, etc.)

Needs support with technology or online learning

Often Tired

Possible substance use

Consistently Oppositional

Consistently Inattentive

Poor impulse control or hyperactivity

Frequent Peer Conflict

Other:

Required

Do any of the following sound appropriate for this student to try?
*

Executive Functioning Skill-building Group: focuses on improving organization and planning

Check-in/Check-out: student checks in with a trusted staff member or older peer before and after school each day

Stress & Anxiety Management Group: focuses on practicing strategies to manage stress/anxiety

On-going individual counseling

On-going group counseling

Other:

Required

Expected Outcome(s) *

Please describe your goal(s) for this student and the expected outcome of this request.

Any additional Information that will help us assess this student’s needs:

Name of staff member you would like to reach out (if you know) and the best method and time to contact you. (for example: Please call after 5:30pm)* *

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