2018-2019 Piedmont Middle School Student Guidance Needs Survey for PARENTS
STATEMENT ON INFORMED CONSENT:
Information obtained in a counseling session will not be disclosed to parents, teachers, outside agencies, or other school personnel without student's permission except when such disclosure is necessary to "protect student or someone else from imminent harm" or is otherwise legally and/or required by law such as abuse or neglect of a child, elder, or disabled person. I may also be required to provide information to the court if provided with a court order
Student Name, Optional
Last Name, First Name
Student(s) Grade Level
To better serve your student(s) through individual or small group sessions, please check the following needs or concerns that apply to your student(s) or family.
Recent death in family
Parent in Jail/Prison
Alcoholism or substance abuse
Anger and Aggression
Other medical concerns
Please check the top 3 areas that you think need to be addressed school-wide.
Substance Abuse Awareness
Career Readiness Skills
Self Respect, Self Awareness and Personal Growth
Personal Safety Skills including Social Media Safety
Respect for Diversity
Please use the space below to share any other information with the school counselor:
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