Family Needs Request

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Please use this form to request assistance with any need that is impacting your child or family.
The Gurdon Wellness Center staff will assist you in CONFIDENTIALLY addressing your family needs through direct assistance, referrals to outside providers, connections to community resources or other avenues.

This form does not serve as a guarantee of assistance. Please expect to be contacted within 2-5 business days.

Student Name(s) *

Student Grade(s) *

Parent/Guardian Name *

Parent/Guardian Address *

Please provide a current telephone number for parent/guardian. *

Please provide a current email address for parent/guardian. *

Please let us know how we can be of assistance. *

My family needs assistance with food.

My child needs clothing.

My child needs hygiene items.

My child needs school supplies.

My child needs to see a doctor.

My child needs to see a dentist.

My child needs to see a counselor.

Other:

Is there any other information that we need to know in order to best assist you?

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