Parent/Legal Guardian Request for Counseling Services
Please complete this form to request counseling or social work services for your student.  Please complete a separate form for each student.  You will be contacted in response to this request to discuss possible services.
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Parent/Legal Guardian Name
Parent/Legal Guardian Phone Number
Parent/Legal Guardian Email
Student Name (legal name as seen in Skyward - may put preferred name in parenthesis after legal name)
School Name
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Student Grade
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Request for services:  Please note any of the options below that you would approve based on your child's need and service availability.  Please note that for counseling with an outside agency we will need to   seek your consent to release information.  (Select all that apply)
Brief description of concern:  ie. academic concerns, withdrawing from friends, school stress/anxiety, family issues, etc.  This information will be confidential, seen only by district counseling staff unless permitted to share with other counseling staff/providers (see next question). It will be used only to determine most appropriate services.
I give my permission to release the above information to the school based staff or an agency representative for the purpose of making a referral
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Submit
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