Student Services Questionnaire

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Please fill out this form to the best of your ability. Our Student Services Coordinator, Rianna Kubly, will likely reach out to you regarding your answers to go over more information. If you have any questions or concerns, please email rkubly@wivcs.org. Please know that your answers here are confidential and will only be used for support purposes.

Thank you!

The more details you include, the quicker I can get support to you!

Email *

Learning Coach's Name: *

Student's name(s):

If there are multiple WIVA students in the family, please list all of them.

Which, if any, of the following describes your student/student's family?

Military family (retired or active services)

Migrant family (Family new to the country)

English Language Learner

Foster Child

Which of the following currently describes your student's housing situation? *

Stable/Permanent housing (Family owns or rents the home)

Shared housing with other persons due to economic hardship, loss of housing, or similar reason

Living with relatives due to economic hardship, loss of housing, or similar reason

Staying in hotels, motels, or campgrounds due to economic hardship, loss of housing, or similar reason

Staying shelters, emergency housing, or temporary housing

Staying in public spaces that are not traditionally meant for living (such as one's car, bus stations, abandoned buildings, car parks, etc.)

An abandoned or vacant property that the family does not have ownership of; "squatting"

Other:

How many people are in the student's close family? (Parents, guardians, siblings, other family members residing with student permanently) *

How many people are living with the student? (This might vary if you are experiencing shared housing or temporary housing, please give the most recent number) *

If your/the student's family qualifies for resources through Student Services, how much support would you prefer?

No support meaning the family does not need/want any resources at this time

Frequent/Heavy Support meaning frequent contact by Student Services Coordinator, as many supports as we have to offer

No support

Frequent/Heavy Support

What are some areas/resources that you need support in? *

Is your student or a member of the family currently experiencing any Mental Health or Physical Health issues that you would like resources/support on? *

Yes

If you answered yes to the previous question, please share a few details about what you are looking for.

Do you have any questions for the Student Services Coordinator? Is there anything you want them to know immediately?

Submit

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