School Counseling/Community Services Request Form

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The counseling program is available to every student currently at Polk elementary. The school counseling program is able to provide short term interventions that include: social skills group, individual skill building and short term counseling focused on teaching emotion regulation skills. These interventions last between 4 to 8 sessions depending on the need of the student. The counseling team is also able to provide referrals for therapy, housing, clothing, hygiene and food resources.

Email *

Record my email address with my response

Childs name *

Service requested *

Social skills group

Individual skill building

Emotion regulation counseling

Basic need request, food, clothing, shelter or housing

Briefly describe your concerns. *

What are your child's strengths? *

How is your child doing in school? *

Has your child had problems at school in the past? *

Have you spoken to your child's teacher about your concerns?

Yes

Other:

Clear selection

By signing this form I give the counseling team permission to work with my student. *

Submit

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