Parent Input Intervention Form
Please use this form if you would like to provide additional information for your student's intervention
Your Student's First and Last Name
Your Student's OLCHS ID#
Your First and Last Name
Are you the student's parent or legal guardian?
Please list some of your student's strengths.
Please check all areas of concern you have
Social or Emotional
Behavioral - attendance or discipline related
Please describe what persistent struggles you see your student having:
Please check any OLCHS staff member you have contacted with your concern
No, I have not contacted anyone yet.
Yes, my student's counselor
Yes, my student's dean
Yes, my student's teacher (list name below)
If your student is receiving outside assistance please let us know:
Professional Counselor, Therapist, Social Worker or Psychologist
Please list anything you have done at home that has helped your student succeed (i.e. removed distractions while studying)
If you have any other comments, recommendations, or questions, please feel free to add them here.
What is the best way to reach you? Please include your phone number or email address.
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