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Parent Counseling Request
Please fill out this form if you would like a counselor to visit with your student.
Counselor Contact Information
Nicole Rodriguez (972) 843-6108
mary.rodriguez@communityisd.org
Pamela Vance ( 972) 843-6113
pamela.vance@communityisd.org
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* Indicates required question
Parent/Guardian Name
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Your answer
Parent/Guardian Phone Number *Used only if we need to follow up*
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Your answer
Student Name (First and Last)
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Your answer
Student Grade Level
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Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
Reason for requesting a counselor *choose as many as applies*
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Drastic change in behavior (Ex: failing grades, emotional outbursts, social isolation, loss of interest in things)
A loss (ex: death of a loved one or pet, loss of friendship, divorce, etc.)
Anger
Suspect bullying or witnessed bullying
Relationship with friends/peers
Relationship with adults (parents/teachers)
Relationships with brothers/sisters or other family members
Feelings of negativity, discouragement, self-doubt
Unhealthy or unsafe choices (thoughts of suicide, self harming behaviors, skipping school)
Study Skills, grades, and schoolwork
Goal planning
Discontinued mental health treatments (stopped counseling, stopped medication, etc)
Other (please leave detailed description)
Option 7
Required
Other details
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Your answer
IF you or someone you know needs immediate help, call 9-1-1. Calling the suicide hotline for them to speak with a counselor or taking them to the nearest ER for a psychological evaluation is important* 24 Hour Crisis Hotline at 1-877-422-5939
Your answer
When should we meet with your student? **Counselors will try their best to accommodate your request** If this is an emergency please call the counselor and/or the school during school hours of 7:30-3:00 pm. If it is after hours, please CALL 911 or visit the nearest ER.
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URGENT (today)
This week
After speaking with the counselor (Counselor will make contact to discuss details)
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