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RHS Support Request Form:
Please use this form to refer a student for Intervention and Support Services. Information will be kept confidential.
Para los padres que necesiten el "Google Form" en español, pueden encontrar el enlace debajo:
https://docs.google.com/forms/d/e/1FAIpQLSdjTy05Xta_GQWOkRMZbaW-_-29zBUV-xHqqWUwsBjiA0zkMA/viewform
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* Indicates required question
Email
*
Your email
Referrer's Name:
*
Your answer
I am a :
*
Choose
Parent/Guardian
Student
Self Referred
Other
Student's Name:
*
Your answer
Student UID:
Your answer
Student's Grade Level
*
9th
10th
11th
12th
Required
Date:
*
MM
/
DD
/
YYYY
Student's Counselor:
*
Rebekah Ames (A-BI & all IT Academy Students)
Anabel Marquez (Bm-Bz & ELL Students)
Claire Miller (C-Fi)
Ashley Gonzales (Fj-Hm)
Lauren Figueroa (Hn-La)
Odessa Perkins (Lb-Pb)
Salvador Garcia (Pc-Sans)
Mindy Munoz (Sant-Z)
Other:
Academic Concerns (check all that apply):
Grade of "F" in more than two classes
Refuses to attend School
Refuses to do homework
Lack of motivation
Credit deficiency
Social-Emotional/Behavioral Concerns (check all that apply):
Attitude or behavior
Needs encouragement
Family concerns
Physical changes
Substance abuse (alcohol, tobacco, or drugs)
Defiant of authority
Harassment of other students
Fighting and/or provoking a fight
Runaway
Abusive language
Other:
Mental Health Concerns (please explain):
Your answer
Briefly explain the reason for request:
*
Your answer
Have other interventions/supports been offered and/or implemented ? Please explain:
*
Your answer
A copy of your responses will be emailed to the address you provided.
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