School Counseling Support Request

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Name of person making request *

Your email address *

Student's last name *

Student's first name *

Grade level *

Student's teacher *

What is your relationship to the student being referred? *

Parent/Guardian

Teacher

Administrator

Other:

Is the parent/guardian aware of this request for school counseling *

Yes, I am the parent/guardian

Yes, I have made contact with the parent/guardian about my request for this student to receive school counseling support

No, the aprent/guardian has not been contacted

Does the student currently receive any support services through the school? *

Check all that apply.

504

ELL

Resource

Speech and Language

Reading Intervention

Occupational Therapy (OT)

None

Other (If other, please describe in the last section)

Required

Has the student participated in any sort of counseling in the past? *

Yes (if yes, please explain below)

No (if no, skip to the next question)

I am not sure

Please explain any counseling the student has participated in.

What are the student's strengths? *

What are the student's challenges? *

I would like this student to learn more about: *

Check all that apply. Please note that checking boxes below does not guarantee that support will be provided in that area. All support is based on need and program availability at the school counselor's discretion.

Academics

Anxiety

Coping strategies

Family dynamics (divorce, separation, living with non-parent relative...)

Greif/loss

Emotional regulation

Self-advocacy

Self-esteem

Self-regulation

Social skills/peer relationships

Other (If other please explain below)

Required

Please use this space to share information related to your request for school counseling support.

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