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Request For Assistance Form: Student
* Indicates required question
Email
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Record my email address with my response
Name:
*
Your answer
Student ID:
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Your answer
Date:
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Your answer
Grade:
*
9th
10th
11th
12th
Required
I am requesting assistance for (check one)
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Myself
A Friend
I need help with.... (Check all that apply)
*
Behavior
Academics
Home Life
Emotions
Attendance
My Physical Health
Mental Health
School Environment
Negative Thinking
Bullying
Abuse
Threats
Other:
Required
In the past, teachers/staff have tried to help by providing...(Check all that apply)
*
Behavior Support
Counseling
Tutoring
After School Program
Meeting With Teacher
Classroom Modifications
I Have Never Asked For Help Before
Other:
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