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Consultation Request Form
This form is for families who are thinking of removing a child from the public school system. The professionals at Deep Root Center are here to listen and help. We will be in touch within 24 hours of receiving this form.
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* Indicates required question
Child(ren)'s Preferred Name(s)
*
Your answer
Child(ren)'s's DOB
*
Your answer
Child's Grade Level
*
Your answer
Parent or Guardian Name(s)
*
Your answer
Parent Email
*
Your answer
Mailing Address
*
Your answer
School District
*
Your answer
Cell Phone 1
*
Your answer
Why are you seeking our help? (check as many as apply)
*
School Refusal - child refuses to go
Medical Excuse for not attending school - denied
Anxiety or depression because of school
Bullying
Not being served by the School
Child has become apathetic or disinterested and says they "hate" school or learning
Child has developed adverse behaviors
Child has been diagnosed with various conditions (ODD, OCD, ADHD etc.)
Other:
Required
Which service are you interested in learning about?
*
In-person membership
Homeschool at home with Deep Root Center consultation services
Not sure - I want to learn more
Neither - checking out all our options first
Required
Where did you hear about DRC?
*
Word of Mouth
Social Media (Instagram or FaceBook)
Brochure, Postcard, or Poster in the community
School Guidance Counselor
Mental Health Counselor or Doctor
DSS or CPS
Other:
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