Conway Springs Counseling Services

Tu navegador no tiene JavaScript activado, por lo cual no se puede abrir este archivo. Actívalo y vuelve a cargarlo.

Dear Parent or Guardian,
We appreciate any consideration you may give to this type of assistance for your child. If you would like your child to able to receive counseling services at any point during the school year, please complete, sign and return the following forms to school.

There are two sections to complete this process:
Concerns checklist: This form helps us identify what specific areas that you and you and your child wish to work on in counseling. It also identifies your child's strengths.
Parental Informed Consent: This form allows your child to participate in counseling.

Please call or email me with any questions, concerns, or progress that you may wish to hear about or report.

Sincerely,

Alisha Cox
Kyle Trueblood and Middle School Counselor
cox@usd356.org

Kristy Martin
High School Counselor
martin@usd356.org

(620) 456-2966 ext.1019 Kyle Trueblood Elementary
(620) 456-2965 ext. 2107 Middle School
(620) 456-2963 ext. 3102 High School

Iniciar sesión en Google para guardar lo que llevas hecho. Más información

First and Last Name of Student *

Grade *

Concern Checklist (check all that apply) *

feels sad, often tearful

diminished pleasure in activites

weightloss/gain

difficulty sleeping

loss of energy

feelings of worthlessness

difficulty making decisions

thoughts or statements of wanting to die

makes careless mistakes

follows directions poorly

difficult maintaining attention

fails to finish tasks

often loses things

trouble remembering things

easily distracting difficulty sitting still

often "on the go"

difficulty waiting for a turn

wants to boss others

initiates fights; bullies others

has been physically cruel to people

has been physically cruel to animals

takes things that don't belong to him/her

starts fires

lies often

destroys property

swears and/or name calls

unpredictable behavior

loses temper easily

argues with adults

refuses to comply with rules

denies responsibility for actions

easily annoyed

often angry and resentful

birth of sibling

witnessed violent act

has been sexually abused

repetitive play

frequent nightmares

diminished interest in activities

sense of foreshortened future

has many fears

difficulty concentrating

irritability or anger outbursts

"walking on egg shells"

clings to parent

distress when separated from parent

refusal to go to school

need to sleep with parent

reluctant to be alone

repeated physical complaints

bed wetting

soiling

worries excessively

prefers to play by self

withdraws from group activity quickly

shyness

has difficulty expressing self

upset if makes mistakes

feelings easily hurt

talks bad about self

blames self if things go wrong

loss of a parent

divorce

parent in jail

recent divorce/split in family unit

loss of a family member

loss of an animal

recent move

illness of family member

Otro:

Obligatorio

If "other" please explain:

Please list at least THREE strengths of your child: *

What is your view of the problem/concern? *

What times are you able to talk with your child's counselor? *

Borrar formulario

Nunca envíes contraseñas a través de Formularios de Google.

Este formulario se creó en Conway Springs School District #356. Denunciar abuso

Formularios