Academic Support Student Self-Referral

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

Please fill this out if you'd like to meet with Ms. Alex and brainstorm ways to make school better for you!

Name *

Grade *

School *

My phone number or email address *

I am having trouble with... *

Check that all apply!

Reading: sounding out words

Reading: understanding what I read

Writing

Math

Science

Social Studies

Knowing what my schoolwork is and when it is due

Completing my work

Turning in my work

Staying organized

Focusing during class or while working on schoolwork

Feeling motivated in school

Feeling anxious or worried about school

Feeling overwhelmed with everything I have to do

Required

Please share more information about your situation.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Student U.

Does this form look suspicious? Report