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Parent/Guardian Referral Form
Parent/Guardian: Please utilize this form to express any concern(s) regarding a personal, home, academic, or social need. Responses will be recorded and sent to the appropriate person needed to address your concern(s).
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* Indicates required question
Parent Name
Your answer
Grade
*
9
10
11
12
Student Name
*
Your answer
Relationship to Student
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
I have a concern and my child may need SELF CARE support with one of the following:
Anxiety / Stress Management
Life changes
Mental Health Concern
Self Esteem / Confidence Building
Unhealthy or Unsafe Choices
Something is wrong, but I dont know what
Other:
I have a concern and my child may need HOME support with one of the following:
Family Difficulties / Concerns
Grief / Loss of a family member, pet, or friend
Other:
I have a concern and my child may need ACADEMIC support with one of the following:
Attendance / Tardies
Grades / Test Taking / Study Skills
Post Secondary Planning
Time Management / Organization Skills
Other:
I have a concern and my child may need SOCIAL support with one of the following:
Bullying
Friends / Peer relationships and / or conflict resolution
Teacher (or staff member) and students conflict or concern
Other:
Briefly explain and elaborate on the nature of your concern(s) below so that we may be able to support your child more effectively. Thank you.
*
Your answer
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