(9th-12th) Request for Assistance Form

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

(9th-12th) Request for Assistance Form - Faculty/Staff

Email *

Name of student: *

Your name: *

Relationship to student: *

Teacher

Office Staff

Other:

Required

Area of concern (Please describe in next section): *

Academic Concerns

Behavioral Concerns

Social Concerns

Emotional Concerns

Physical Health Concerns

Family Concerns

Other:

Required

Description of concern(s): *

Behavioral Concerns (Please mark all boxes that apply): *

Exposed to community violence, other trauma

Nightmares, intrusive thought

Anxious, fearful or irritable mood

Jumpy or easily startled

Avoids reminders of trauma

Aggressive

Sexualized play or behaviors

Difficulty concentrating

Talks excessively

Gets out of seat and moves constantly

Interrupts and blurts out responses

Inattentive, distractible, forgetful

Disorganized, makes careless mistakes

Angry toward others, blames others

Fights and is aggressive

Argumentative and defiant

Sad, depressed or irritable mood

Hopelessness, negaitve view of future

Low self-esteem, negative self-statements

Diminished interest in activities

Low or decreased motivation

Anxious and fearful

Worries excessively

Difficulty Sleeping

Restless and on edge

Specific fears or phobias

Clingy behavior

Appears distracted

Required

How often is this behavior occurring? (e.g., several times per day; 1-2 times per week):

How long has this behavior been occuring? (e.g., several weeks, several months):

To your knowledge, what interventions have previously been tried, but were unsuccessful? In school supports:

To your knowledge, what interventions have previously been tried, but were unsuccessful? Outside of school supports:

To your knowledge, what interventions are currently in place? In school supports:

To your knowledge, what interventions are currently in place? Outside of school supports (ex: tutoring):

Clear form

Never submit passwords through Google Forms.

Forms

This form was created inside of Hughson Unified School District.