EHE Parent/Guardian School Counseling Request Form (2021-2022)

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Please fill out the form below if you would like to request for one of the School Counselors (Mrs. Jednat or Mrs. Brady) to meet with your child.

*NOTE: Mrs. Jednat and Mrs. Brady will be available to meet with students regarding areas of their academic, behavioral, social and emotional needs. Direct services the School Counselors can provide in the school setting include short-term individual counseling, crisis intervention, small group counseling, and restorative practices. As part of the indirect services School Counselors may also provide referrals for parents/guardians seeking outside mental health or community based services. Under no circumstances are the intended services the School Counselor provides to your child a substitute for psychological counseling, therapy, or diagnosis. It is the responsibility of the parent/guardian to determine whether additional services are necessary and whether to seek them for their child.

Email *

First Name (Child) *

Last Name (Child) *

Grade *

Who is your child's teacher? *

Name of referring person *

Reason for request *

Anxiety

Divorce

Adjustment/Transition

Peer/Friendship Issues

Sadness/Withdrawn

Anger Management

Self-Esteem/Self-Confidence

Grief/Loss of a loved one

Social Skills

Other

Required

What is a goal you would like your child to work towards/accomplish during their time with the School Counselor? *

Would you like information about community based resources and mental health services? *

Yes

Please include any other information that may be helpful for the School Counselor to know ahead of time to better assist your child.

Submit

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