ENCINAL'S REQUEST FOR ASSISTANCE
Students and family members can request help for a student by using this form. Encinal staff members should use Aeries to make this kind of request.
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Name of Student
Student's grade level:
What is your name?
I am requesting support in the following area(s):
Why are you making this request? Check all that apply to the student.
Needs support with technology
Low grades/lack of work completion
Issues related to depression
Withdrawn/Isolated from peers
Basic Needs are not being met (food, shelter,clothing, hygiene)
Health Issues (vision, dental, stomach, headaches, etc.)
Possible substance use
Poor impulse control or hyperactivity
Peer Group Issues: Change in group or isolation
Often missing class
Do any of the following sound appropriate for this student to try?
Peer tutoring: another student helps with various subjects/assignment/skills
Executive Functioning Skill-building Group: focuses on improving organization and planning
Check-in/Check-out: student checks in with a trusted staff member or older peer before and after school each day
Stress & Anxiety Management Group: focuses on practicing strategies to manage stress/anxiety
Prosocial behavior/Friendship Group: focuses on improving social skills and reducing peer conflicts
Young Men's/Young Women's Group: provides a positive environment to connect with peers of the same gender identity
On-going individual counseling
On-going group counseling
None of the above
Please describe your goal(s) for this student and the expected outcome of this request.
Any additional Information that will help us assess this student’s needs:
Contact information for referring party: Phone number or email address
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This form was created inside of Alameda Unified School District.