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(Fox Road) Request for Assistance Form - Student (Self/Peer)
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* Indicates required question
Your FIRST & LAST name
*
Your answer
Your STUDENT EMAIL
*
Your answer
Grade Level
*
4th
5th
Other:
Who are you looking for support for?
Myself
Another student at my school
Clear selection
The school's care team may wish to contact you to understand your concerns better.
Yes, It's ok to contact me
No, please don't contact me
Clear selection
Contact information (Optional)
Your answer
Please share the reason you are seeking support for yourself or another student. (Please mark all boxes that apply)
*
Exposed to community violence, other trauma
Nightmares, intrusive thought
Anxious, fearful or irritable mood
Jumpy or easily startled
Avoids reminders of trauma
Aggressive
Sexualized play or behaviors
Difficulty concentrating
Talks excessively
Gets out of seat and moves constantly
Interrupts and blurts out responses
Inattentive, distractible, forgetful
Disorganized, makes careless mistakes
Angry toward others, blames others
Fights and is aggressive
Argumentative and defiant
Sad, depressed or irritable mood
Hopelessness, negaitve view of future
Low self-esteem, negative self-statements
Diminished interest in activities
Low or decreased motivation
Anxious and fearful
Worries excessively
Difficulty Sleeping
Restless and on edge
Specific fears or phobias
Clingy behavior
Appears distracted
Required
Please share any additional information you would like the care team to know
Your answer
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