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Parent Input Intervention Form
Please use this form if you would like to provide additional information for your student's intervention
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* Indicates required question
Your Student's First and Last Name
*
Your answer
Your Student's OLCHS ID#
Your answer
Your First and Last Name
*
Your answer
Are you the student's parent or legal guardian?
Parent
Legal Guardian
Other:
Clear selection
Please list some of your student's strengths.
Your answer
Please check all areas of concern you have
Academic
Social or Emotional
Behavioral - attendance or discipline related
Other:
Please describe what persistent struggles you see your student having:
Your answer
Please check any OLCHS staff member you have contacted with your concern
*
No, I have not contacted anyone yet.
Yes, my student's counselor
Yes, my student's dean
Yes, my student's teacher (list name below)
Other:
Required
If your student is receiving outside assistance please let us know:
Professional Tutor
Professional Counselor, Therapist, Social Worker or Psychologist
Psychiatrist
Medical doctor
Other:
Please list anything you have done at home that has helped your student succeed (i.e. removed distractions while studying)
Your answer
If you have any other comments, recommendations, or questions, please feel free to add them here.
Your answer
What is the best way to reach you? Please include your phone number or email address.
Your answer
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