Request to Connect with Quest Academy Mental Health Team

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Thank you for reaching out to the mental health team! Please complete this form and someone from our team will be in contact with you within 72 hours. IF THIS IS AN EMERGENCY, please call CHAMPS at 202-481-1440 for 24/7 emergency psychiatric support.

Email *

Parent Name *

Please provide the best number to reach you. *

Student Name *

Do you have students attending other KIPP schools? *

Yes

Please select your student's grade level. *

1st grade

2nd grade

3rd grade

4th grade

Does your student have a 504 Plan or an IEP? *

Yes- 504 Plan

Yes- IEP

I'm not sure

I have the following concerns for my child that I would like to discuss with the school mental health team (check all that apply): PLEASE NOTE: If this is an emergency, please call CHAMPS at 202-481-1440 for emergency psychiatric support. *

Mood changes

Anxiety/worry

Grief & loss

Explosive behavior

Aggression/fighting

Self-Harm or suicidal statements

Attention/lack of focus

Sleep problems

Family conflict

Problems accessing/participating in remote learning

Other

Required

Do you need to discuss any of the following with a member of the school team? *

Assistance with housing

Access to employment resources

Access to childcare resources

Assistance securing meals

Assistance securing clothing

Other

None of the above

Required

Please agree to the following: *

I understand that by submitting this form, I am requesting to discuss the identified issues with my child's mental health team. I understand that someone will respond to my request within 72 hours.

I understand that this form is not to be used in cases of emergency, and that if I am in need of emergency mental health services for my child, I can contact CHAMPS at 202-481-1440 for 24/7 crisis support.

Required

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