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Jackson Heights School Counseling Request Form
This request is for school based counseling. Although we are happy to provide referrals to behavioral counseling, our focus is on school success.
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Email
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Your email
Student Name:
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Your answer
Parent/Guardian Name and contact phone number.
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Your answer
Reason for Request:
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Academics ( grades, attendance, participation, work completion, school avoidance)
Social Emotional ( Grief, Self-Esteem, Family Concerns, Shy/Withdrawn, Unhappy, Worried)
Self-Regulation ( Behaviors, Bullying, Impulsive, Hyperactive, Excessive Talking, etc.)
Parenting ( Helping your child with homework, sleep times for success in school, consistency between school and home, friends and teachers)
Other:
Child's Strengths
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Your answer
Information the School Counselor should know in order to assist your child more effectively. (e.g. family situation, medical, past experiences, or any concerns that apply to this student's situation.)
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Your answer
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This form was created inside of Red Bluff Union Elementary.
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