KSSN Basic Needs Request Form Glenwood
This request form is designed to help your Community School Coordinators best identify supports to help students and families. The Coordinators will process your request and will connect students and families with the most appropriate resources. They may reach out to you to get more information or to follow up with you regarding identified concerns. All information in this request form is confidential.

Please note: This request form should not be used for crisis situations, including:
  • suicidal ideation or serious self-harm
  • abuse or neglect
  • violent behaviors or threats of violence
Crises should be brought immediately to the appropriate school staff.
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Student Name *
Parent or Guardian Name *
Parent or Guardian Contact Information
Has the parent or guardian been informed that this request is being made? *
Request Source: What is your name and email address? *
What is your role? *
Student Concerns (select all that apply) *
Required
Notes:  Please provide more information regarding specific concerns that have been selected above.  
Family Concerns (select all that apply) *
Required
Notes: Please provide more information regarding specific family concerns selected above.
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