Request for Counselor Support Form
Teachers, Parents, and Students:

Please use this form if you would like to request that I follow-up with a student, parent, and/or family member to support them during this school year. This form can be used for the following reasons:

*Teacher/Parent/Caregiver consultation on ways to support students and children.
*Direct support for students.
*Assist families in connecting with community resources (food access, financial assistance, counseling, etc).
*Request to check-in with a student/family to assess that they are healthy and safe.

Best Regards,
Russell Sass
School Counselor
Glenmoor Elementary

School site number: 510-797-0740
Google Voice number: 510-972-8008
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Who is making the school counseling referral? *
What is the child's first and last name? *
Please provide your name and specific relationship to the student.  *
Your email address: *
Please include the best contact information and way to reach the family? (Email, phone, other)  
What type of school counseling help is being requested? *
Please provide a brief and general description of the concern you have or the outcome you are seeking.  (i.e. I need a resource for tutoring, I want the student to handle conflict better, etc.)
Thank you for filling out this form! I will follow-up with referrals within 1 or 2 business days. I am wishing you health and safety throughout the school year.
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