REQUEST FOR ASSISTANCE

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

Alameda High School students and family members can request help for a student in one of four areas of need: academics, behavior support, social-emotional health, or attendance.

Email *

First and Last Name of Student *

Grade Level of Student: *

I am requesting support in the following area(s): *

Academics

Behavior

Social-Emotional Health

Attendance

Other:

Required

Why are you making this request? Check all that apply to the student. *

Lack of work completion

Symptoms of depression

Inconsistent school attendance

Withdrawn/Isolated from peers

Anxious/Worried

Basic needs are not being met (food, shelter, clothing, hygiene)

Health issues (vision, dental, stomach, headaches, etc.)

Often tired

Speech difficulties

Possible substance use

Consistently oppositional

Physical/verbal aggression

Consistently inattentive/struggle to focus

Poor impulse control or hyperactivity

Frequent peer conflict

Low grades/lack of work completion

Missing credits

Often missing class

Excessive tardies

Language barriers

Other:

Required

Expected Outcome(s) *

Please describe your goal(s) for this student and the expected outcome of this request.

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

Person Referring: First and Last Name *

Person Referring: Relationship to Student *

Does the student know 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