Parent Request for Student Support

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Email *

Student Name *

Name of person requesting support for this student *

Relation to student *

Phone number

What are your main concerns for this student? (Check all that apply)

Academics (Student has low or failing grades)

Behavior (Student is displaying behaviors that are difficult to manage)

Emotional (Student has a hard time regulating emotions)

Mental Health (Student is sad, anxious, or angry most of the time)

Social (Student struggles to make friends)

Medical (Student has health issues)

Please tell us about any behaviors that you have observed within the last month (check all that apply) *

Lack of motiviation

Multiple missing assignments in 2 or more classes

D's or F's in 2 or more classes

Sleeps a lot

Stays up late because they are doing something (tv, phone, gaming, etc.)

Has trouble sleeping

Loss of interest in activities they use to enjoy

Spends most of their time in their room

Emotions are excessive for the size of the problem

Drinks alcohol

Uses marijuana (smoke/vape/edibles)

Abuses over the counter or prescription drugs

Vapes

Steals (from family)

Shoplifts

Is in a gang or dresses and acts like they are gang affiliated

Weight gain

Weight loss due to not eating or excessive exercising

Complains of stomach hurting (no known medical issue)

Is easily angered

Excessive crying

Change in the way they dress

Has a medical diagnosis

Has to take multiple medications

Has experienced the loss of a relative or someone they were close to

Other:

Required

Is there anything else that we should know that may be affecting your student's academics, social/emotional wellbeing, or mental health? (Choosing the right supports for a student is like doing a puzzle. This information can help us understand a student's barriers and gives us more pieces to the puzzle. Examples might include: a recent divorce, a recent re-marriage, a parent currently serving time, a specific traumatic event, etc. We know it can be hard to talk about and appreciate your willingness to share).

Is your student getting counseling or seeing a therapist? *

Yes

I do not know

Student Safety

If you suspect your student could be in danger of hurting themselves, you should call their doctor immediately and share your concerns so your student can be assessed by a professional medical provider. If you think the student may be suicidal call 911.

How would rate your concern for your student? *

Low

Extreme

I understand that I am requesting support for my student & give permission for the school counseling team to share this information with Rio Tierra's Intervention Team (4 people) in order to determine the best supports for my student. *

Yes, I understand and grant permission

I understand but I do not give permission for the information provided to be shared with the intervention team

I am not the student's parent/legal guardian so I cannot consent

Required

Please type your full name as a signature to the above statement *

Submit

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