Counseling Connections Parent/Guardian Form:

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I look forward to helping you and your child with counseling and resource needs. Please complete the applicable parts of this form as needed. If you would rather discuss your needs with me directly, please contact me, Vickie Gordon, at 940-393-7512. Thank you!

Email *

What is your child's first and last name?

What, if anything, would you like for the counselor to know about your child?

Name of parent or guardian completing this form

Preferred method of contact:

Phone

Please provide email or phone number

Please complete the areas of counseling or community services you are interested in below.

Individual Counseling

Individual counseling is brief, lasting no longer than 3-4 sessions and is provided on an as needed basis. Some counseling needs are more complicated than what a school counselor can address. If it is determined that the child's needs will require longer term counseling, the parent will be contacted for referral to community counseling.

I am interested in individual counseling for my child for the need checked below:

Peer relationships

Stress/anxiety

Coping with loss/grief

Anger management

Problem solving

Other (Please specify below)

If other is checked, please specify need:

Lunch Bunch (Group Counseling)

Groups are offered on a rotating basis and will occur one time a week for 4-6 weeks. Groups will be formed on as needed basis. In order to reduce time out of class, sessions will occur during the students' lunch time. Students may bring their lunch or go through the cafeteria line as usual. A permission form will be sent home before the group begins.

I am interested in a lunch bunch/group counseling for my child for the need checked below.

Divorce care/family changes

Friendship skills

Grief/coping with loss

School success

Anger management

What I would like for the counselor to know about my child before placing him/her in a group:

Community Resource Assistance

Please check any needs you may have below. If you do not see the area you need, please check other and provide information about how counselor can help or contact the counselor directly. The counselor will contact you with information about community resources. Holiday assistance applications will be sent home once they are available from agencies.

Please check which areas you are interested in receiving information:

Holiday assistance (Santa Cops, Wise County Toy Run, Live Thankfully, Coats for Kids)

Clothes closet

Emergency assistance for utilities or rent

Food for family

Feeding Wise Kids (provides supplemental weekend snack food for children)

School supplies

Other (please specify below)

If "other" is checked, please tell me about your need.

Thank you!

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