Parent / Guardian Request for Intervention

Please complete the form below. Required fields marked with an asterisk *

This form is to be completed by parents or guardians who are concerned about their child's attendance, behavior, mental health, substance use, or academic challenges. If this is a life threatening situation where your child is in danger of hurting themselves or others call 911 or go to the nearest emergency room.

Student's First Name*

Answer required for "Student's First Name"

Student's Last Name*

Answer required for "Student's Last Name"

Student's Grade*

Answer required for "Student's Grade"

Parent / Guardian Name*

Answer required for "Parent / Guardian Name"

Parent / Guardian Phone Number*

Answer required for "Parent / Guardian Phone Number"

My child is struggling with anxiety

Answer required for "My child is struggling with anxiety"

Yes

Sometimes

Unsure

My child has been suffering from depression for at least 2 weeks or more

Answer required for "My child has been suffering from depression for at least 2 weeks or more"

Yes

Sometimes

Unsure

My child experiences angry outburst more than 3 times a week

Answer required for "My child experiences angry outburst more than 3 times a week"

Yes

Sometimes

Unsure

My child is failing 1 or more of his/her classes

Answer required for "My child is failing 1 or more of his/her classes"

Yes

Unsure

My child is anxious around a lot of people and it is affecting his/her attendance, motivation, and academics

Answer required for "My child is anxious around a lot of people and it is affecting his/her attendance, motivation, and academics"

Yes

Sometimes

Unsure

My child has been coming home under the influence of alcohol or drugs

Answer required for "My child has been coming home under the influence of alcohol or drugs"

1x a week

2x's a week

more than 2x's a week

Unsure

My child recently underwent a loss or crisis. Please share your concerns

Answer required for "My child recently underwent a loss or crisis. Please share your concerns"

Please fix the highlighted areas below before submitting.

Parent / Guardian Request for Intervention