Love's Request for Assistance

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Students and family members can request help for a student by using this form. Once you make a request, the Love Student Support team will meet to discuss how we can best support the student. We will then follow up with you. *Note: Love staff members should use AERIES to make this kind of request.

Email *

Name of Student *

Student's Grade Level *

What is your name and relationship to the student? *

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

Academics

Behavior

Social Emotional Health

Attendance

Required

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

Lack of work completion

Withdrawn/isolated from peers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

Consistently oppositional

Physically/verbally aggression

Poor impulse control or hyperactivity

Consistently inattentive

Frequent peer conflict

Other:

Required

Expected Outcome(s): Please describe your goal(s) for this student and the requested outcome of this request. *

Any additional information that will help us assess this student's needs:

Contact information for referring party: Phone number or email address *

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