Counseling Survey
Hi Patriot Families! My name is, Alicia Klinker, and I am the counselor at Patriot. If you would please take a few minutes to fill out this survey in order for me to best support student needs this year I would greatly appreciate it. This information will also help me create small groups that will run throughout the school year. If you would like your child to participate in small group please know a permission slip will be coming home and your child may not participate in group until spring. I will also be screening who participates in group this year in order to best serve students. If your student may need supports and group is not the best fit, please know I will reach out and see the best way I can help. This information stays confidential and only the mental health team has access to it. Please reach out with any questions or concerns.

Alicia Klinker, Counselor
aklinker@ffc8.org
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Email *
Parent/Guardian filling out form *
Student name (if you have more than one student please fill out a separate form for each) *
Students Teacher *
My student needs help identifying and communicating emotions and needs. *
My student deals with a high amount of anxiety. *
My student needs help making and keeping friends. *
My student needs help with their self-esteem. *
My student needs help with making good decisions. *
My student needs help with school based skills such as organization, advocating for themselves about school needs, goal setting, etc. *
I would like my child to participate in small group counseling during the 21-22 school year. *
Do you need any food, clothing, or holiday gift support? District 8 has access to resources that we can help connect you with if needed. *
Required
Is there anything that would be beneficial for the mental health team to know to best support your child this year? This information remains confidential.
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