Wolfpack and Rise Counseling Request Form for Parents/Guardians

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form is to provide an opportunity for parents/guardians to request support for their students.

Once we receive this request, we will contact you before the end of the next school day to determine how we can best support your student.

Thank you,
Mr. Herrera and Mr. Rivas
School Counselors
The Leadership Academy and Rise

Parent/Guardian Name: *

Email Address *

Telephone Number: *

Student Name: *

Grade *

Best way to reach you: *

Phone

Best time to reach you: *

Morning (8:00 AM- 10:30 AM)

Early Afternoon (11:00 AM- 1:00 PM)

Late Afternoon (1:30 PM- 3:00 PM)

Concerns (please check all that apply): *

My student is not motivated to complete distance learning assignments

My student is struggling with the distance learning assignments

Our family needs help finding community resources

I am concerned about my student's mental health/safety

I am concerned about my student's behavior at home

Required

Any additional details:

**Important Reminder**

This form is for non-emergencies only. If it is an emergency (thoughts of harming self or others), do NOT email School Counselor. Call 911 or text HOME to 741741 or call the National Suicide Prevention Line: 1-800-273-8255. If you have immediate concerns for a child's safety and/or believe they are victims of abuse, please make a DCFS report or call 911.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of LANCASTER SCHOOL DISTRICT. Report Abuse

Forms