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(9th-12th) Request for Assistance Form - Faculty/Staff
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* Indicates required question
Email
*
Your email
Name of student:
*
Your answer
Your name:
*
Your answer
Relationship to student:
*
Teacher
Office Staff
Other:
Required
Area of concern (Please describe in next section):
*
Academic Concerns
Behavioral Concerns
Social Concerns
Emotional Concerns
Physical Health Concerns
Family Concerns
Other:
Required
Description of concern(s):
*
Your answer
Behavioral Concerns (Please mark all boxes that apply):
Exposed to community violence, other trauma
Nightmares, intrusive thought
Anxious, fearful or irritable mood
Jumpy or easily startled
Avoids reminders of trauma
Aggressive
Sexualized play or behaviors
Difficulty concentrating
Talks excessively
Gets out of seat and moves constantly
Interrupts and blurts out responses
Inattentive, distractible, forgetful
Disorganized, makes careless mistakes
Angry toward others, blames others
Fights and is aggressive
Argumentative and defiant
Sad, depressed or irritable mood
Hopelessness, negaitve view of future
Low self-esteem, negative self-statements
Diminished interest in activities
Low or decreased motivation
Anxious and fearful
Worries excessively
Difficulty Sleeping
Restless and on edge
Specific fears or phobias
Clingy behavior
Appears distracted
How often is this behavior occurring? (e.g., several times per day; 1-2 times per week):
Your answer
How long has this behavior been occuring? (e.g., several weeks, several months):
Your answer
To your knowledge, what interventions have previously been tried, but were unsuccessful? In school supports:
Your answer
To your knowledge, what interventions have previously been tried, but were unsuccessful? Outside of school supports:
Your answer
To your knowledge, what interventions are currently in place? In school supports:
Your answer
To your knowledge, what interventions are currently in place? Outside of school supports (ex: tutoring):
Your answer
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