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Island High Request for Assistance
This form is for students and/or families to request support and services.
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* Indicates required question
Name of Student
*
Your answer
Student's Grade Level
*
Choose
9
10
11
12
What is your name?
*
Your answer
I am requesting support in the following areas:
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Academics
Behavior
Social-emotional/mental health
Attendance
Other:
Required
Why are you making this request?
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Low/no credit earning
Issues related to mental health (depression, anxiety, etc.)
Issues with peers (isolated/withdrawn, new peer group, frequent conflicts, etc.)
Basic needs are not being met (food, shelter, clothing, hygiene)
Physical health issues (vision, dental, stomachaches, headaches, etc.)
Tired/exhausted, sleep schedule is dysregulated
Speech difficulties
Possible substance use
Physical/verbal aggression, oppositional behavior
Poor impulse control/hyperactivity/attention issues
Attendance (missing or cutting class, excessive tardies, etc.)
Other:
Do any of the following interventions sound appropriate?
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Check-in/Check-out: student checks in with a trusted staff member or older peer before and after school each day
Individual counseling/therapy
Group counseling/therapy
Meeting with student's teachers, counselor & principal to discuss concerns
Required
Desired outcome: Please describe your goal(s) for this student and the desired outcome of this request.
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Your answer
Any additional Information that will help us assess this student’s needs:
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Your answer
Contact information for referring party: Phone number and/or email address *
*
Your answer
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