Request for supports

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

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.

Email *

Last Name of Student *

First Name of Student *

Grade Level *

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? *

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Withdrawn/Isolated from peers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): *

Any additional Information that will help us assess this student’s needs:

Person Referring: Name *

Person Referring: Relationship to Student *

Person Referring: Preferred contact information *

Does the student know that you are referring them? *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Alameda Unified School District.

Does this form look suspicious? Report

Forms