REQUEST FOR ASSISTANCE

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Students or family members can request help for a student by using this form. Staff members should use Aeries to make this request.

Email *

Name of Student: *

Student's grade level: *

First grade

Second grade

Third grade

Fourth grade

Fifth grade

What is your name and relationship to the student? *

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

Academics

Behavior

Social-Emotional Health

Attendance

Other:

Required

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

Basic Needs are not being met (food, shelter,clothing, hygiene)

Health Issues (vision, dental, stomach, headaches, etc.)

Withdrawn/Isolated from peers

Anxious/Worried

Lack of work completion

Often Tired

Inconsistent School attendance

Speech difficulties

Consistently Oppositional

Physical/verbal aggression

Consitently inattentive

Frequent Peer Conflict

Other:

Required

Expected Outcome(s) *

Please describe your goal(s) for this student and the expected outcome of this request.

Have you talked to your child's teacher prior to filling out this request? *

Yes

Other:

Would you like help arranging a meeting with your child's teacher about your concerns? *

Yes

Other:

Have you talked to your student's case manager or principal if your child has an IEP or 504 plan prior to filling out this request?
*

Yes

N/A

Other:

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

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

Your answer

A copy of your responses will be emailed to the address you provided.

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