Parent Counseling Request Form
Tarbiyah Academy is happy to provide counseling services for students for a variety of issues. Based on need, students have access to both individual and group counseling, and can be given resources/referrals depending on the issues they are facing. Please fill out the form below and provide information on what your child is experiencing so we can find the best fit for him/her.
Also, please feel free to reach out to me via email at fatimakhan@tarbiyahacademy.org with any questions.
Jazakumullahu-Khrain!
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Your Full Name *
Your relationship to the student *
Student Name *
Grade Level *
What are you referring your scholar for? *
Required
What services would you like to request? *
Required
I would like (check all that apply) *
Required
Student knowledge of referral *
Has this concern been discussed with your child's teacher? *
Has your child been in counseling in the past or is he/she currently in counseling or therapy? If yes, please briefly describe the counseling services. *
Does your child have any Mental Health or Physical Health diagnosis? If yes, please share the diagnosis and whether or not the child is aware of it. *
Is there any additional concern/service request you would like me to know about?
Please provide your preferred email address and phone number *
Thank you for taking the time to complete this form! I will review your responses and reach out to you via email to discuss next steps shortly Inshallah.
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