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 is
for a referring a student for direct counseling services. For counseling referrals please use the
Student Counseling Referral Form
This form (
Request for Counselor Support)
would be used to request the following:
*Teacher/Parent/Caregiver consultation on ways to support students and children.
*Assistance for families in connecting with community resources (food access, financial assistance, community counseling, etc).
*Check-in with a student/family to assess health and safety.
School site number: 510-797-0740
Google Voice number: 510-972-8008
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* Indicates required question
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?
Check-in to assess student/family's safety and well-being. Please note that if you have concerns that it is an emergency, please contact a medical/safety professional and seek the appropriate help.
Referrals to community resources (food banks, financial assistance, housing concerns).
Teacher/Parent/Caregiver consultation to support student's well-being and healthy functioning.
Teacher/Parent/Caregiver consultation to support family's well-being and healthy functioning. c
Direct counseling support for students.
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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This form was created inside of Fremont Unified School District.