School Support Request Form

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Complete the information below if you are needing supports for counseling, basic needs, or technology help

Email *

I am a *

Parent/ Guardian submitting a request for my child

Staff member submitting a request

Name of person making referral *

Best way to contact you (email or phone number) *

Name of student *

Students teacher *

Grade *

1st

2nd

3rd

4th

5th

What are you requesting support for *

Mental or Emotional Health

Personal/Family Concern

Peer Conflict

Teacher Conflict

Academic Concern

Technology Support

Basic Needs (food or clothing...)

Other

Additional information you would like to share

Is this an emergency *

Yes

In the case of emergency call 9-1-1 or proceed to the nearest emergency room. If you are in crisis (ANY painful emotion, for which you need support), text HOME to 741741. Within minutes, a crisis counselor will text you back to start a conversation. If needed, you may call the Suicide Prevention Hotline @ 1-800-273-8255. You may also call the Seven Counties Services 24 hour Crisis and Information line at (502)589-4313

I understand that if this is not an emergency, it could take 2-3 school days to be contacted *

Yes

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This form was created inside of Jefferson County Public Schools.