Request to Connect with Mental Health Team
Thank you for reaching out to the mental health team! Please complete this form and someone from our team will be in contact with you within 72 hours. IF THIS IS AN EMERGENCY, please call CHAMPS at 202-481-1440 for 24/7 emergency psychiatric support.
Sign in to Google to save your progress. Learn more
Parent Name *
Please provide the best number to reach you. *
Student Name *
Do you have students attending other KIPP schools? *
Please select your student's grade level. *
Does your student have a 504 Plan or an IEP? *
I have the following concerns for my child that I would like to discuss with the school mental health team (check all that apply): PLEASE NOTE: If this is an emergency, please call CHAMPS at 202-481-1440 for emergency psychiatric support. *
Required
Do you need to discuss any of the following with a member of the school team? *
Required
Please agree to the following: *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of KIPP DC.

Does this form look suspicious? Report

Google Forms