Request For Support - Appointment/Feedback Form
With distance learning, (30 min) check-ins are being offered for students who are experiencing elevated challenges and may be in need of additional support in the area(s) of:
* managing schedule/free-time/boredom
* managing relationships with others within the home
* managing challenging school work
* maintaining calming/energizing strategies
* managing fears/concerns/anxiety
This is not considered individual telehealth counseling, but referrals to other outside providers can be provided if requested.
With in-person learning now in effect, we are offering ( 30) min support groups and individual sessions. There will be 6 support session in total topic will include:
* Social Skills
* Worries/ Anxiety
* Changing Families/ Divorce
Please complete this permission/form. Mrs. Badak (School Behavioral Health Professional) or Mrs. Hanrahan (School Counselor) will be in touch with you as soon as possible. We want to help!
Student First & Last name, Grade, Homeroom Teacher
My concern is
Academic (managing schedule/workload/technology)
Emotional Well-Being (managing feelings/stress)
Social (relationship with family and/or friends)
Check all that apply:
Support services at school have been offered in the past
Support outside of school has been pursued and is still in effect
Support outside of school has been pursued, but is not happening at this time
New concern since school has started
A brief summary of your concern (Optional):
Who is completing this form and relationship to the student?
Please share your preferred method of contact to YOU (email/phone):
By completing and submitting this form, you are giving permission for staff/student contact. Please check to indicate the methods you allow for contact between your child and Mrs. Badak and/or Ms. Hanrahan.
In person indivial support session
Video call via google suite
Group support session ( will include 3 or less students per group)
Continue to take care of YOURSELF, too!
Never submit passwords through Google Forms.
This form was created inside of School District of Palm Beach County.