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Golden Valley Student Support Request Form (Tier II)
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* Indicates required question
Email
*
Your email
Name of Requestor
*
Your answer
Student Name
*
Your answer
UID (6 Digit Number)
*
Your answer
Date
*
MM
/
DD
/
YYYY
Grade
*
9
10
11
12
Student Counselor &/or Program Specialist
*
Lupe Sanchez (A-Ce)
Vanessa Castaneyra (Ch-Gom)
Victoria Hinojosa (Gon-Mars)
Giselli Garcia (Mart-Po)
Ramon Cardenas (Pr-Ti)
Emmanuel Gomez -Head Counselor-(To-Z and All ELD students)
Melissa Sitton (Program Specialist - PLEASE SELECT FOR SPECIAL EDUCATION)
Required
Type of Concern (Mark All That Apply)
*
Academic
Behavior or Social-Emotional
Attendance
Community Resources (Food Box, Clothing, Hygiene Products)
Required
For this Tier II Referral, has parent contact been made by the teacher by PHONE? *Remember, the best Tier I practice is a phone call by the teacher. If translation is needed, please contact Jane Hurttgam in the Title I Office.
*
Yes
No
For this Tier II Referral, has parent contact been logged into Synergy with the appropriate date of contact?
*
Yes
No
What interventions have been provided by the requester so that the student may be #BulldogSTRONG. (Please check all that apply. Tier II/III team will verify documentation in Synergy.)
*
Phone Call Home to Parent/Legal Guardian/Emergency Contact (BEST TIER I STRATEGY)
Tutoring
Previous Tier II Form
GPS/#BulldogSTRONG Recognition (Postcard/Google Form)
Contacted Counselor
Email through Synergy
Message Notification through Canvas
Support Staff Intervention (i.e. Instructional Aid calling home, Social Worker, Interventionist)
None
Other:
Required
Briefly describe the reason for the request.
*
Your answer
A copy of your responses will be emailed to the address you provided.
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