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

Student's Last Name*

Answer Required

Student's Grade*

Answer Required

Parent / Guardian Name*

Answer Required

Parent / Guardian Phone Number*

Answer Required

My child is struggling with anxiety

Answer Required

Yes

Sometimes

Unsure

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

Answer Required

Yes

Sometimes

Unsure

My child experiences angry outburst more than 3 times a week

Answer Required

Yes

Sometimes

Unsure

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

Answer Required

Yes

Unsure

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

Answer Required

Yes

Sometimes

Unsure

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

Answer Required

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

Please fix the highlighted areas below before submitting.

Parent / Guardian Request for Intervention