(23-24 SY) Parent Contact Request Form
Hello Parents!
If you would like me to contact you or your student please complete the following questions. Please remember that if this is a medical/mental health emergency call 911. I will be checking the responses on this form daily but please give me 1-2 days to reach out. I would also like to remind you that school counselors practice confidentiality when working with your student. Everything discussed is confidential unless your student discloses that they are/plan to hurt themselves, others, or someone is hurting them (physically, emotionally, and/or sexually).
Thank you!

Ms. Jadee Lu

家長您好！ 如果您希望我聯繫您或您的孩子，請填寫以下問題。請記住，如果這是醫療/心理健康緊急情況，請撥打 911。我將每天檢查此表格上的回复，但請給我 1-2 天的時間與您聯繫。我還想提醒您，學校輔導員在與您的孩子交谈时所有內容都是保密的，除非您的孩子向我透露：正在計劃傷害自己或他人；有人正在傷害他们或他人。 謝谢您的理解和配合！ Ms. Jadee Lu

Email *
Students First and Last Name 
學生姓名 *
Students Grade Level 
學生年級 *
Your First and Last Name
 您的姓名
 *
Your Relationship to Student 
  您與學生的關係
 *
How would you like the school counselor to contact you?
您希望學校輔導員如何與您聯繫？
 *
Please provide the phone number or email you would like to be reached at.  
  請提供您希望我聯繫的電話號碼或電子郵件。
 *
Please check the best date to contact you. 
請選擇可以与您聯繫的最佳日期。
 *
MM
/
DD
/
YYYY
Please choose the best time that I can reach you. 
請選擇我能聯繫到您的最佳時間。
 *
Time
:
What topic would you like to talk about?
您想与我談論什麼話題？
 *
Required
Please provide a short summary of what your concerns are.   請簡要概述您的擔憂 *
I understand that the school counselor may not receive this request immediately if this is a crisis please contact emergency services at 911. I also understand that anything discussed with the school counselor or anything my student discusses with the school counselor is confidential unless I or my student discloses that they want to or are hurting themselves or others or is being hurt physically, emotionally, or/and sexually. 
我明白，學校輔導員可能不會立即收到此问卷表格，所以如果出現紧急情况請撥打911 聯繫緊急服務。我同意，我與學校輔導員討論的任何內容或我的學生與學校輔導員討論的任何內容都是保密的，除非學生透露：正在計劃傷害自己或他人；有人正在傷害他们或他人。
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