Parent/Caregiver Check-In with the School Counselor

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Parents are facing new challenges every day! It is important to take care of our children's mental health, but at the same time it is important that we take are of ourselves! This form gives you access to potential resources and ideas to help support your child's and your own mental health.

Name *

Child's Name(s) and Teacher's Name *

Date *

YYYY

Best Way to Contact You* *

Phone Call

Text Message

Other:

Required

I would like resources for my child related to:

Worry/Anxiety

Grief/Loss

Depression/Sadness

Motivation

Future Planning for High School

Future Planning for After High School

Social Skills/Friendship

Anger/Defiance

Other:

I would like resources for myself or another adult related to:

Community Resources

Healthy Coping Skills

Troubleshooting your child's mood or behavior

Clear selection

In order to ensure a follow up response, please leave your number and/or email. I will probably contact people the day after responses are submitted. If you are experiencing immediate mental distress, please contact: SAMSHA's National Helpline 1-800-662-HELP (4357)

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