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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.
NOTE:
This form is
NOT
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.
Best Regards,
Russell Sass
School Counselor
Glenmoor Elementary
School site number: 510-797-0740
Google Voice number: 510-972-8008
rsass@fusdk12.net
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* Indicates required question
Who is making the school counseling referral?
*
Parent/Caregiver
Student
Teacher/Staff
Other
What is the child's first and last name?
*
Your answer
Please provide your name and specific relationship to the student.
*
Your answer
Your email address:
*
Your answer
Please include the best contact information and way to reach the family? (Email, phone, other)
Your answer
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.
Other:
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.)
Your answer
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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