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Request for supports
Students and family members can request supports for a student in one of four areas of need: academics, behavior support, social-emotional health, or attendance. Alameda High School staff members should use Aeries to make this request.
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* Indicates required question
Email
*
Your email
Last Name of Student
*
Your answer
First Name of Student
*
Your answer
Grade Level
*
Your answer
I am requesting support in the following area(s):
*
Academics
Behavior
Social-Emotional Health
Attendance
Required
What are the strengths (positive characteristics) of this student?
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Your answer
Why are you making this request? Check all that apply to the student.
*
Symptoms of depression
Withdrawn/Isolated from peers
Anxious/Worried
Basic Needs are not being met (food, shelter, clothing, hygiene, etc.)
Health Issues (vision, dental, stomach, headaches, etc.)
Often Tired
Speech difficulties
Possible substance use
Consistently Oppositional
Physical/verbal aggression
Poor impulse control or hyperactivity
Consistently inattentive/struggle to focus
Peer Conflict
Low grades/lack of work completion
Missing credits
Often missing class
Excessive tardies
Other:
Required
Mark all of the following supports that may be appropriate for this student to try?
*
Peer tutoring: another student helps with various subjects/assignment/skills
Academic Coaching: another student helps with a specific subject/assignment/skill
Executive Functioning Skill-building Group: focuses on improving organization and planning
Check-in/Check-out: student checks in with a trusted staff member before and after school each day and have teachers complete a Daily Progress Report
Stress & Anxiety Management Group: focuses on practicing strategies to manage stress/anxiety
Pro-social behavior Group: focuses on improving social skills and reducing peer conflicts
Young Men's/Young Women's Group: provides a positive environment to connect with peers of the same gender identity
On-going individual counseling
On-going group counseling
Other:
Required
Expected Outcome(s)/goal(s):
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Your answer
Any additional Information that will help us assess this student’s needs:
Your answer
Person Referring: Name
*
Your answer
Person Referring: Relationship to Student
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Your answer
Person Referring: Preferred contact information
*
Your answer
Does the student know that you are referring them?
*
Yes
No
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